Sherman Village Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in North Hollywood, California.
- Location
- 12750 Riverside Drive, North Hollywood, California 91607
- CMS Provider Number
- 056159
- Inspections on file
- 68
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 49 (1 serious)
Citation history
Health deficiencies cited at Sherman Village Hcc during CMS and state inspections, most recent first.
A resident with multiple comorbidities, severe cognitive impairment, and dependence on staff for ADLs developed bluish discoloration on the upper arm, after which the physician ordered all blood thinners held for three days. Despite this, Eliquis 2.5 mg was documented as administered twice that day via G-tube, contrary to the order. An RN and the DON acknowledged this as a medication error with potential for bleeding, and the facility’s own medication administration policy required adherence to prescriber orders, which was not met.
Surveyors found that the facility lacked a formally appointed, properly licensed Administrator (ADM) serving as the NHA and did not have consistent on-site administrative oversight. Staff reported that the prior ADM had left, the Department Head Directory did not list an ADM, and a regional ADM only visited a few hours several times per week without a formal appointment letter. The receptionist also noted that this temporary ADM had been absent for several days due to a corporate conference, leaving the DON identified only as the Abuse Coordinator and no clearly designated ADM present to manage operations.
A resident with diabetes, neuropathy, and an amputation did not receive person-centered activity interventions as outlined in their care plan. Despite documented needs and preferences for self-directed and in-room activities, staff failed to conduct activity rounds or offer appropriate interventions unless specifically requested, resulting in a lack of activity engagement for an extended period.
A resident with diabetes, neuropathy, and an amputation, who was cognitively intact and required some assistance, did not receive a resident-centered activity program. Activity staff did not proactively offer group or in-room activities, nor did they assess the resident's preferences, resulting in a lack of engagement unless the resident specifically requested it. The DON confirmed that daily activities and proper documentation were not provided as required by facility policy.
A resident with severe cognitive impairment and multiple medical conditions was administered amlodipine despite a physician order to hold the medication for systolic blood pressure below 110 mmHg. The medication was given when the resident's blood pressure was 105/76 mmHg, contrary to the order and facility policy requiring verification of vital signs before administration.
A resident with multiple medical conditions and severe cognitive impairment did not have accurate documentation in the medical record regarding medications that were held per physician orders. Although a nurse stated she did not administer certain blood pressure and heart failure medications when the resident's blood pressure was low, the MAR reflected that the medications were given and did not indicate they were held, contrary to facility policy.
A resident on enhanced barrier precautions due to a wound and G tube received care from an LVN who failed to wear a protective gown as required by facility policy and physician orders. The LVN provided G tube care wearing only gloves, despite clear signage and protocols indicating the need for both gloves and a gown. Both the DON and IP confirmed that proper PPE was not used during this high-contact care activity.
A resident with multiple medical conditions experienced a significant change of condition, including tachycardia and oxygen desaturation, requiring transfer to a hospital. The facility failed to document complete and accurate information on the resident's Change of Condition form, omitting details about oxygen administration and vital sign monitoring, despite facility policy requiring such documentation.
A resident with cognitive impairment, dysphagia, and a history of elopement was not provided with the required supervision and monitoring as outlined in their care plan and physician orders. Staff failed to supervise the resident during meals, did not perform or document required visual checks, and were unaware of the resident's elopement risk. Inadequate handoff and documentation practices resulted in the resident's absence going unnoticed for hours, leading to the resident eloping from the facility, suffering a fall, and requiring hospital care.
Surveyors found that several residents, including those with severe mobility limitations and cognitive impairments, did not have their call lights or specialty pad call lights within reach. In multiple cases, call lights were tied to bed rails, placed on the paralyzed side, or left hanging out of reach, contrary to facility policy and care plans. Staff interviews confirmed the devices were not positioned properly, impacting residents' ability to summon assistance.
Surveyors found that several residents were subjected to physical restraints, such as raised side rails and tab alarms, without proper assessment, physician orders, or informed consent. In some cases, pillows and blankets were used as barriers under bedding without care planning, and required entrapment risk and restraint assessments were not completed. Staff interviews confirmed these practices did not follow facility policy, resulting in residents' freedom of movement being restricted without appropriate justification or documentation.
Two residents received psychotropic medications without proper evaluation, documentation, or informed consent. One resident was given PRN lorazepam without a stop date, specific behavioral criteria, or consistent monitoring for side effects, and informed consent was not properly documented. Another resident was prescribed risperidone for schizophrenia without a confirmed diagnosis in the clinical record, care plan, or MDS, and both the resident and her representative were unaware of such a diagnosis. Facility staff acknowledged these failures did not align with policy requirements for psychotropic medication use.
Four residents at risk for pressure injuries did not receive care consistent with professional standards when their low air loss mattresses were either not set according to their weight or were not promptly replaced after malfunctioning. In two cases, mattresses were set incorrectly, and in two other cases, residents remained on deflated mattresses for hours, with staff confirming the risk for skin breakdown. All residents had significant medical conditions and required total assistance, and the facility's own policies and manufacturer guidelines for mattress use were not followed.
Surveyors found that several residents did not have their urinals labeled with identifiers, and one resident's indwelling catheter tubing was not anchored as required. Staff confirmed that these actions did not follow facility policy and could result in cross-contamination and increased infection risk, particularly urinary tract infections.
Surveyors found that staff failed to properly label enteral feeding and water flush bags with required information such as resident name, room number, administration rate, date and time hung, and nurse initials. In several cases, the administration rate on the formula bottle did not match the rate set on the feeding pump. These deficiencies were observed in multiple residents with severe cognitive impairment and complex medical needs, and staff interviews confirmed that facility protocols for safe administration were not consistently followed.
The facility did not complete required entrapment risk assessments and quarterly restraint assessments for the use of bed rails and side rails for several residents, including one with severe cognitive impairment and others with significant physical disabilities. In some cases, bed rails were installed without prior assessment for entrapment risk, and all four side rails were raised for a resident without proper assessment, order, or informed consent, contrary to facility policy and best practices.
Three residents with diabetes received subcutaneous insulin injections without proper rotation of injection sites, contrary to physician orders, manufacturer guidelines, and facility policy. Nursing staff repeatedly administered insulin in the same anatomical locations, and both nursing leadership and staff acknowledged this as a medication error. Facility records and interviews confirmed that the electronic medication administration system was not used to ensure site rotation, resulting in non-compliance with professional standards.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident or their representative was not informed of their choice to enter into a binding arbitration agreement or their right to refuse, as required. The facility did not provide the necessary information about the arbitration process or the option to decline participation.
Surveyors identified multiple lapses in infection control, including an unclean shower room with feces and discarded dressings, torn and taped dryer gaskets in the laundry area, failure by an LPN to use required PPE when entering a contact isolation room, another LPN not donning a gown during direct care for a resident on Enhanced Barrier Precautions, and a dirty, possibly contaminated trash can in a shared resident bathroom that was not promptly reported or replaced. These deficiencies were confirmed through staff interviews, observations, and policy reviews.
Multiple residents did not have comprehensive care plans developed or implemented for key interventions, including psychotropic medication monitoring, use of side rails, low air loss mattresses, anticoagulant therapy, fall risk management, and elopement risk. In several cases, care plans were missing, not updated in a timely manner, or not followed, leading to staff being unaware of necessary interventions and resulting in missed monitoring, environmental hazards, and an actual elopement event.
Licensed nursing staff failed to rotate insulin injection sites for several residents with diabetes, administering injections repeatedly in the same areas despite physician orders, facility policy, and manufacturer guidelines. Additionally, staff did not provide required supervision and monitoring for a resident at risk for elopement, aspiration, and falls, resulting in the resident leaving the facility unsupervised and experiencing a fall. These deficiencies were confirmed through record reviews and staff interviews.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
Nurses and nurse aides failed to demonstrate the competencies needed to provide care that maximizes each resident's well-being, resulting in a deficiency related to staff qualifications and skills.
Staff failed to accurately document physician responses, treatment administration, and resident status in clinical records. For example, a nurse did not record a physician's order after a resident's fall, respiratory therapy documentation was missing for two treatments, and a CNA inaccurately charted a resident's meal intake without checking the tray. Additionally, a nurse used an earlier blood pressure reading for a later time and failed to document observed crying spells as required by physician order.
Two residents were administered psychotropic medications without proper informed consent. In one case, the consent form did not match the medication preparation actually given, and in another, the responsible party was not contacted to discuss the risks or benefits of new medications before administration. Facility staff confirmed that required consent procedures were not followed, contrary to facility policy.
The facility did not ensure that residents were informed of their right to file a complaint with the State Survey Agency, and failed to provide visible, readable, and accurate contact information. Multiple residents were unaware of where to find this information, and both the AD and DON confirmed that the posted details were not accessible or correct, contrary to facility policy.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident lost the ability to perform ADLs without a documented medical reason. The facility did not ensure that the decline in the resident's functional abilities was clinically unavoidable, as required by regulations.
A resident did not receive enough food and fluids to maintain their health, as observed and documented by surveyors. The facility did not ensure the resident's nutritional and hydration needs were met.
A resident receiving continuous oxygen therapy was found with nasal cannula tubing touching the floor and an illegible change date, contrary to facility policy and infection control standards. Staff interviews confirmed the tubing should not contact the floor and must be properly labeled, but these procedures were not followed for a resident with a history of sepsis, pneumonitis, and COPD.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A discrepancy was found in the accounting of a controlled medication when a nurse failed to document the administration of an oxycodone dose immediately after giving it to a resident. Additionally, a resident with complex medical needs did not receive multiple scheduled medications on time, with a delay of nearly four hours. Both the nurse and DON confirmed that these actions were not in line with facility policy, which requires timely administration and documentation of medications.
A resident's Quarterly MDS assessment was not completed and submitted within the required 92-day timeframe, as confirmed by the MDS Director and DON. The assessment was submitted on the 93rd day, exceeding federal requirements, despite the use of an MDS Scheduler intended to track due dates.
A resident with multiple complex diagnoses had their admission MDS assessment submitted to CMS after the required timeframe. The MDS was completed and transmitted late, as confirmed by facility records and staff interviews, in violation of established policies and federal requirements.
A resident with severe cognitive impairment and a gastrostomy tube was found with the feeding tube tip lying uncovered on the floor after being disconnected, contrary to facility policy and best practices. Staff confirmed the tube should have been capped and secured to prevent infection, but this was not done.
The facility failed to prevent mice from entering residential rooms, affecting four residents with conditions like hypertension and anxiety disorder. Mice were reported by visitors and confirmed by the Maintenance Supervisor, who captured them in the rooms. The facility's pest control and infection prevention policies were not effectively implemented, as pests should not be present due to potential disease risks.
The facility failed to maintain a safe and sanitary environment by allowing mice in resident rooms, affecting four residents with conditions like hypertension and anxiety disorder. Staff interviews and photographic evidence confirmed the presence of mice, despite existing policies aimed at preventing such infestations.
The facility failed to maintain an effective pest control program, resulting in mice being found in rooms occupied by four residents with various medical conditions. Staff and visitors confirmed the presence of mice, and the Maintenance Supervisor provided photographic evidence of captured mice. The facility's pest control policy, last revised in 2008, was not effectively implemented, leading to this deficiency.
The facility failed to ensure that call lights were within reach for several residents, including those with severe cognitive impairments and high fall risks. Observations revealed that call lights were placed out of reach, contrary to the facility's policy, leading to potential delays in care. Staff interviews confirmed the oversight, highlighting a lapse in adhering to care plans and procedures.
The facility failed to provide a homelike environment by not repairing broken bathroom flooring for a resident, not providing flat sheets on pressure-reducing mattresses for two residents, and not maintaining cleanliness of a resident's desk fan. These deficiencies led to unsafe and uncomfortable conditions for the residents.
The facility failed to ensure residents were free from physical restraints without proper authorization, affecting five residents. Restraints such as bed rails and hand mittens were used without physician's orders, assessments, or informed consents, contrary to facility policy. This included improper use of side rails and mittens, posing risks to resident safety and dignity.
The facility failed to rotate injection sites for insulin and anticoagulant administration for several residents, as required by professional standards and facility policy. This deficiency was identified through interviews and record reviews, revealing repeated injections in the same areas, increasing the risk of adverse effects like lipodystrophy and bruising. The DON confirmed that licensed nurses did not follow the expected practice, placing residents at risk of harm.
The facility failed to ensure a safe environment for residents, with issues including malfunctioning sensor pad alarms, beds not kept at low positions, and unstable equipment placement. These deficiencies were observed for several residents, increasing the risk of falls and injuries.
The facility failed to properly label and manage feeding tube equipment for several residents, leading to potential risks of altered nutritional status and complications. Water flush bags and feeding bottles were not labeled with necessary information, and an LPN did not check a resident's gastrostomy tube placement before starting enteral feed, contrary to facility policy.
The facility failed to administer IV fluids according to professional standards for two residents. A resident's IV site showed signs of infiltration, and documentation of dressing changes and flushing was incomplete. Another resident's peripheral IV catheter was not reassessed for necessity post-antibiotic treatment, and dressing changes were not performed weekly. These deficiencies exposed residents to potential complications.
The facility failed to properly assess and manage the use of bed rails and restraints for several residents, leading to potential safety risks. A resident with quadriplegia had all four side rails up without proper documentation or assessment. Another resident had pillows under the mattress as a restraint without an assessment. A third resident had all four side rails up, contrary to the physician's order for bilateral upper half side rails. These deficiencies were confirmed by staff interviews.
A facility failed to implement a consultant pharmacist's recommendations for a hospice resident with diabetes and depression. Despite the pharmacist's advice to monitor blood sugar with a HgA1C test and consider a dose reduction for Escitalopram, these actions were not taken. The attending physician disagreed with the recommendations without providing a documented rationale. The resident's clinical record lacked necessary documentation, and the facility did not adhere to its policies, risking unnecessary medication use.
Failure to Hold Anticoagulant as Ordered, Resulting in Significant Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when staff did not follow a physician’s order to hold a blood thinner. The resident, who had diagnoses including age-related osteoporosis with a pathological fracture of the right humerus, epilepsy, and type 2 diabetes mellitus, had a history and physical indicating they lacked capacity to understand and make decisions, and an MDS showing severely impaired cognitive skills and dependence on staff for activities of daily living. A change of condition form documented that the resident was observed with bluish discoloration on the inner upper right arm in the late evening, and the physician subsequently ordered all blood thinners to be held for three days. Despite this order, review of the resident’s MAR for April showed that Eliquis 2.5 mg was administered via G-tube at both the morning and evening administration times on the day the hold order was in effect. During interviews, an RN acknowledged that administering Eliquis after the physician ordered it to be held was a medication error with the potential to cause bleeding, and the DON stated the Eliquis was to be held until the cause of the discoloration was identified. The facility’s medication administration policy required that medications be administered safely, timely, and as prescribed, in accordance with prescriber orders, which was not followed in this instance.
Lack of Formally Appointed and Consistently Present Administrator
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed Administrator (ADM) was formally appointed and serving in the capacity of a Nursing Home Administrator (NHA), and that an ADM was present for sufficient hours to provide adequate oversight and management of operations. During observation and interview, the DON’s license was posted in the lobby identifying the DON as the Abuse Coordinator, but there was no indication of an appointed ADM. The facility’s Department Head Directory did not list an ADM, and staff interviews confirmed that the previous ADM had left on January 10, 2026. Staff reported that since the prior ADM’s departure, an interim or regional ADM had been coming to the facility only approximately three times per week for a few hours per visit, either in the morning or afternoon. The receptionist stated that the temporary ADM had been absent from the facility for the past three days due to attending a corporate conference. The DON confirmed that the regional ADM providing oversight did not have a formal appointment letter designating them as the Administrator and had been assigned by the corporate office. As a result, the facility was operating without a consistently present, formally appointed, and properly licensed ADM responsible for managing and overseeing facility operations.
Failure to Implement Person-Centered Activity Care Plan
Penalty
Summary
The facility failed to implement a person-centered care plan for one resident by not following documented interventions related to the resident's preference for not attending group activities. The resident, who had diagnoses including diabetes mellitus with neuropathy, an amputation below the right knee, and left shoulder pain, was admitted with intact cognitive skills and required some assistance with daily activities. The care plan specified that staff should encourage self-directed activities and conduct rounds to monitor and offer appropriate interventions for activity needs. Despite these documented interventions, interviews and record reviews revealed that activity staff did not conduct room visits or offer in-room activities unless specifically requested by the resident. The resident reported that activity staff had not inquired about his preferences for in-room activities and that he enjoyed making a ball from rubber elastic bands, but this interest was not addressed. Activity staff confirmed that the resident only attended group activities when his room was being deep cleaned and that no group or in-room activity visits occurred for a one-month period. The Director of Nursing acknowledged that the care plan interventions were not followed, emphasizing that staff should have encouraged self-directed activities and monitored the resident's activity needs as outlined in the care plan. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that activity plans should be developed with resident participation and included in the total care plan. However, these requirements were not met for this resident, resulting in a failure to deliver necessary care and services as planned.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing, resident-centered activity program for one resident with diabetes, diabetic neuropathy, an amputation below the right knee, and left shoulder pain. The resident was cognitively intact and required staff setup assistance for certain activities of daily living. Documentation showed that the resident's care plan included participation in group and independent activities, as well as room visits. However, interviews and record reviews revealed that the resident did not receive activity room visits and was not asked about preferences for in-room activities. The resident reported that activity staff had not inquired about his needs for in-room activities and that he enjoyed making a ball from rubber elastic bands, but this interest was not addressed. Activity staff confirmed that the resident only attended group activities when his room was being deep cleaned and that no room visits or group activities were provided from 11/1/2025 to 12/1/2025 unless specifically requested by the resident. The activity staff did not proactively visit the resident or offer activities unless the resident asked. The Director of Nursing acknowledged that daily activities should be provided and documented, including refusals, and that lack of daily activity could negatively impact the resident's self-esteem. Facility policy required assessment of resident interests and the development of individualized activity plans, but these procedures were not followed for this resident.
Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders for one resident by not holding amlodipine when the resident's systolic blood pressure (SBP) was below the prescribed threshold. Specifically, the physician order directed that amlodipine be held if the SBP was less than 110 mmHg. Despite this, the medication was administered when the resident's SBP was recorded at 105/76 mmHg. This action was confirmed through review of the Medication Administration Record and interviews with the Assistant Director of Nursing and the Director of Nursing, both of whom acknowledged that the medication should have been withheld according to the order. The resident involved had multiple diagnoses, including sepsis, lobar pneumonia, and essential hypertension, and was dependent on staff for all activities of daily living with severely impaired cognitive skills. The facility's policy required that medications be administered as prescribed and that vital signs be checked and verified prior to administration when necessary. The failure to follow the physician's order and facility policy resulted in the administration of a blood pressure-lowering medication despite a low SBP reading.
Failure to Accurately Document Held Medications in Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by not properly documenting medications that were held according to physician orders. Specifically, the physician had ordered that certain blood pressure and heart failure medications be held if the resident's systolic blood pressure was below 110 mmHg. Despite this, the Medication Administration Record (MAR) indicated that these medications were administered on dates when the resident's blood pressure was below the specified threshold. However, the nurse involved stated during interview that she did not actually administer the medications on those dates, but instead must have documented them as given in error. She also failed to document that the medications were held, as required by facility policy. The resident involved had multiple diagnoses, including sepsis, pneumonia, and hypertension, and was dependent on staff for all activities of daily living with severely impaired cognitive skills. The Assistant Director of Nursing and Director of Nursing both confirmed that the nurse should have held the medications and documented this action accurately in the MAR, using the appropriate code for held medications. The facility's policy required that all services provided, including medications administered or held, be documented objectively and completely in the resident's medical record.
Failure to Follow Enhanced Barrier Precautions During G Tube Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for a resident who was on enhanced barrier precautions (EBP) due to the presence of a wound and a gastrostomy (G) tube. According to the resident's medical records, the resident was dependent on staff for all activities of daily living and had severe cognitive impairment. Physician orders and facility policy required staff to wear both gloves and a gown when providing direct care, including G tube care, to prevent the spread of multi-drug-resistant organisms (MDROs). During an observation, a Licensed Vocational Nurse (LVN) entered the resident's room, which had EBP signage posted, and provided G tube care while wearing gloves but without donning a gown. The LVN stated she intended to loosen the G tube before putting on the gown but acknowledged she should have worn the gown before providing care. Both the Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that the LVN should have worn a gown during the procedure, as required by facility policy and the resident's care plan.
Incomplete Documentation of Change of Condition and Oxygen Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting essential information during a change of condition event. Specifically, the Change of Condition (COC) form for the resident did not include documentation of oxygen administration details or comprehensive monitoring of vital signs, such as the amount and timing of oxygen provided. This omission was confirmed during interviews with both the registered nurse involved and the Director of Nursing, who acknowledged that the documentation was incomplete and did not accurately reflect the care and treatment provided. The resident in question had a history of anemia, chronic kidney disease, and urinary tract infection, and was assessed as having moderately impaired cognitive skills, requiring varying levels of assistance with daily activities. On the day of the incident, the resident experienced tachycardia, hypertension, and episodes of oxygen desaturation, ultimately requiring transfer to an acute care hospital. Despite these significant changes in condition, the medical record lacked detailed documentation of the resident's vital signs and the specifics of oxygen therapy administered during the event. Facility policies reviewed indicated that all services, treatments, and changes in a resident's condition should be thoroughly documented in the medical record to facilitate communication among the care team. However, the COC form for this resident did not meet these standards, as it failed to include care-specific details about the treatments performed and the resident's response to those interventions.
Failure to Provide Adequate Supervision and Monitoring Leads to Resident Elopement and Injury
Penalty
Summary
A resident with a history of cognitive impairment, dysphagia, and previous elopement was not provided with adequate supervision and monitoring as required by their care plan and physician orders. The resident was identified as being at risk for aspiration, falls, and elopement, with care plans and physician orders specifying interventions such as supervision during meals, frequent visual checks, and placement near the nursing station. Despite these documented risks and interventions, staff failed to consistently implement and document the required supervision and monitoring. For example, the resident was left unsupervised during mealtimes, and staff were unaware of the supervision order. Documentation of meal intake and visual checks was inaccurate or completed without direct observation of the resident. On the day of the incident, the resident was last seen in their room before lunch, but was not visually confirmed to be present by the assigned CNA, who assumed the resident was in the bathroom and documented meal intake without verifying the resident's presence or consumption. The nurse assigned to the resident did not perform the required blood pressure checks or visual monitoring as ordered, and used earlier readings to fill documentation. During shift change, handoff procedures were insufficient, with staff not being informed of the resident's elopement risk or previous incidents. As a result, the resident's absence went unnoticed for several hours, and staff only became aware the resident was missing during the evening meal service. The resident was later found in the community after having eloped from the facility, suffering a fall and requiring hospital evaluation for trauma and aspiration precautions. Interviews with staff revealed a lack of awareness regarding the resident's elopement risk, required supervision, and the need for individualized care plan interventions. The care plan for elopement was not person-centered and did not include specific interventions such as visual checks or supervision. The failure to implement and communicate required safety interventions, combined with inadequate handoff and documentation practices, directly contributed to the resident's elopement and subsequent injury.
Failure to Ensure Call Lights and Specialty Call Lights Were Within Reach of Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that call lights and specialty pad call lights were within reach for several residents. In multiple instances, surveyors observed that call lights were either tied to bed rails, dangling toward the floor, or placed on the side of the resident's body that was paralyzed or immobile, making them inaccessible to the residents. Staff interviews confirmed that the call lights were not positioned according to facility policy and the residents' care plans, which required call lights to be within easy reach to allow residents to summon assistance when needed. For example, one resident with acute and chronic respiratory failure, tracheostomy, ventilator dependence, and total dependence on staff for activities of daily living was found with the call light tied to the side rail and out of reach. Another resident with hemiplegia and hemiparesis affecting the left side had the call light clipped to the left side, which was not accessible due to paralysis, despite being able to use the right arm. In both cases, staff acknowledged the error and repositioned the call lights after being prompted by surveyors. Additionally, two residents with severe contractures and total dependence on staff, who were provided with specialty pad call lights due to their limited mobility, were found with these devices placed out of reach—either hanging over the side rail or near the floor. Staff and nursing leadership confirmed that the pad call lights should have been placed on the chest or near the face to allow the residents to alert staff for assistance. Facility policies and care plans reviewed by surveyors consistently required that call lights be within reach of all residents, including those with limited mobility or cognitive impairment.
Failure to Ensure Residents' Rights and Proper Use of Physical Restraints
Penalty
Summary
Surveyors identified multiple deficiencies related to the improper use of physical restraints and failure to ensure residents' rights to dignity and freedom of movement. In several cases, side rails were raised on both the upper and lower sides of beds without proper assessment, physician orders, or informed consent. For example, one resident was found with all four side rails raised, despite only having an order and assessment for bilateral upper side rails. Staff interviews confirmed that the lower side rails were raised without authorization, and there was no documentation of an assessment for their safety or need. The facility's own policies require assessment, informed consent, and physician orders prior to the use of restraints, which were not followed in these instances. Another deficiency involved the use of pillows and blankets as physical barriers under a resident's fitted sheet, which was not ordered or care planned. Staff acknowledged that this practice was not standard and could restrict the resident's movement, effectively acting as a restraint. Additionally, for another resident, required entrapment risk assessments and quarterly restraint assessments for the use of side rails were not completed as mandated by facility policy. Staff interviews confirmed that these assessments were missing for multiple review periods, and the use of both upper and lower side rails was not properly evaluated for safety or necessity. Further deficiencies were found in the use of tab alarms for two residents. These alarms, which are considered restraints, were applied without obtaining informed consent or completing initial and quarterly restraint assessments. Staff confirmed that the alarms were in use to prevent falls, but the required documentation and evaluation for their appropriateness and safety were not completed. Facility policies reviewed by surveyors clearly state that restraints, including alarms, require a physician's order, informed consent, and ongoing assessment, none of which were consistently documented or performed in these cases.
Deficient Psychotropic Medication Management and Documentation
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medication use and chemical restraints, as evidenced by multiple deficiencies in the management of psychotropic medications for two residents. For one resident with a history of traumatic brain injury, depression, and anxiety disorder, the facility did not provide ongoing re-evaluation of the need for PRN lorazepam, as the medication was ordered without an end date and continued indefinitely. The orders for lorazepam also lacked specific, measurable behavioral manifestations to guide administration, and there was no consistent monitoring for adverse effects following administration. Additionally, there was no documented evidence of informed consent being obtained prior to the administration of the psychotropic medication, as required by facility policy. Interviews with facility staff, including the MDS nurse, RN, and ADON, confirmed that the facility's process for psychotropic medication management was not followed. Staff acknowledged that PRN psychotropic medications should be ordered with a stop date, monitored for specific behaviors, and that informed consent must be obtained and documented. Review of the medication administration record revealed multiple instances where lorazepam was administered without documentation of side effect monitoring, and the informed consent form did not indicate who provided consent or when it was obtained. For another resident with dementia and a history of alcohol abuse, the facility failed to ensure that the antipsychotic medication risperidone was used only with a clear, documented indication. The resident's clinical record did not contain a confirmed diagnosis of schizophrenia, which was listed as the reason for the risperidone prescription. The diagnosis was questioned in psychiatric notes, and neither the care plan nor the MDS included schizophrenia as an active diagnosis. The resident and her representative were not aware of a schizophrenia diagnosis, and the DON confirmed that the use of risperidone without a clear, confirmed diagnosis was not appropriate. Facility policies required a comprehensive assessment and documentation of a specific condition for psychotropic medication use, which was not met in this case.
Failure to Ensure Proper Use and Timely Replacement of Low Air Loss Mattresses
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards of practice for four residents who were at risk for or being treated for pressure injuries. For two residents, the low air loss mattresses (LALM) were not set according to the residents' current weight or comfort as indicated by both the facility's policy and the manufacturer's guidelines. In one case, a resident weighing 123 lbs was found lying on a LALM set at 240 lbs, despite a sticker on the pump indicating the correct setting should be 120 lbs. Staff confirmed that the mattress should have been set to match the resident's weight, and that failure to do so could affect comfort and increase the risk of pressure injury. Another resident's LALM was set at 160 when the correct setting, based on the resident's weight of 185 lbs, should have been 200, as confirmed by both nursing staff and the assistant director of nursing. For two additional residents, the LALMs were observed to be malfunctioning, with the pump units emitting a beeping sound and a flashing "low pressure" indicator light. Both residents appeared sunk into their beds, and staff confirmed that the mattresses had been in this state for over two hours. The staff and DON acknowledged that the mattresses were deflating or had leaks, and that the residents' buttocks were nearly touching the bed frame, which could lead to skin breakdown. The facility did not have extra LALMs readily available to replace the malfunctioning units, resulting in the residents remaining on inadequately functioning support surfaces for an extended period. All four residents involved had significant medical histories and were at moderate to very high risk for developing pressure injuries, as indicated by their Braden Scale assessments and physician orders for LALM use. The facility's own policies and the manufacturer's guidelines required that LALMs be set according to resident weight and that malfunctioning mattresses be promptly replaced to ensure proper pressure redistribution. The failure to follow these procedures resulted in residents being exposed to improper support surfaces, increasing their risk for the development or worsening of pressure injuries.
Failure to Label Urinals and Secure Catheters Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to provide appropriate care and services to residents who were incontinent of urine, specifically in the areas of urinal labeling and catheter care, as observed and documented by surveyors. Multiple residents, including those with significant medical needs such as respiratory failure, tracheostomy, ventilator dependence, neuromuscular dysfunction of the bladder, and severe cognitive impairment, were affected by these deficiencies. In several instances, urinals used by residents were not labeled with resident identifiers, despite facility policy and staff interviews confirming that labeling is required to prevent cross-contamination and infection. For example, in a shared restroom, an unlabeled urinal was found hanging from a mobility assistance bar, and staff acknowledged that this could result in urinals being used for the wrong resident. Additionally, a resident with an indwelling catheter was observed to have the catheter tubing unsecured, not anchored in the stat lock as required by physician order and facility policy. Staff interviews confirmed that the catheter should have been anchored to prevent accidental tugging or dislodgement, which could cause trauma and increase the risk of infection. The facility's policies on infection prevention, urinal use, and catheter care all specify the need for proper labeling and securement, but these procedures were not followed in the observed cases. Staff, including CNAs, RNs, the Infection Preventionist, and the Assistant Director of Nursing, all confirmed during interviews that the observed practices did not align with facility policy and could lead to cross-contamination and urinary tract infections. The documentation and interviews consistently indicated that the lack of urinal labeling and failure to secure catheter tubing represented a failure to implement established infection control measures for residents who are incontinent or require catheterization.
Failure to Properly Label and Administer Enteral Feedings and Water Flushes
Penalty
Summary
Surveyors identified multiple deficiencies related to the administration and labeling of enteral feeding and water flush bags for residents with feeding tubes. In several cases, staff failed to label water flush bags and formula bottles with essential information such as the resident's name, room number, administration rate, date and time hung, and the initials of the licensed nurse. For example, one resident's water flush bag lacked the resident's name, room number, and infusion rate, and the staff confirmed that both the tube feeding bottles and water flush bags should be labeled with this information to ensure correct administration. Another resident's formula bottle was labeled with an incorrect administration rate that did not match the rate set on the feeding pump, and the water flush bag was also missing required identifying information. The report details that these labeling failures were observed across multiple residents, all of whom had significant cognitive impairments and required total assistance with activities of daily living. The residents had complex medical histories, including tracheostomies, ventilator dependence, gastrostomies, dysphagia, and protein-calorie malnutrition. Staff interviews confirmed that the facility's policy required specific labeling to prevent errors in administration and to ensure that residents received the correct formula and hydration as ordered by physicians. However, observations and record reviews revealed that these protocols were not consistently followed. Additionally, the facility's own policies and procedures, which were reviewed by surveyors, clearly outlined the steps necessary to ensure safe administration of enteral nutrition, including checking the label against the order and documenting all required information. Despite this, staff did not consistently adhere to these protocols, as evidenced by the lack of proper labeling and mismatched administration rates. These deficiencies were confirmed through direct observation, staff interviews, and review of facility policies.
Failure to Assess and Document Safe Use of Bed Rails and Side Rails
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of bed rails and side rails for multiple residents. For one resident with severe cognitive impairment and total dependence on staff for activities of daily living, the facility did not complete required entrapment risk assessments and quarterly restraint assessments for both upper and lower side rails, despite physician orders and care plan interventions indicating their use. Observations confirmed that both upper and lower side rails were up, and staff interviews revealed that this was not in accordance with the resident's care plan and could restrict freedom of movement. For two other residents, both of whom had significant physical impairments but were cognitively intact, the facility failed to assess the risk of entrapment from bed rails prior to installation. Although physician orders and informed consent were documented, there was no evidence of an entrapment risk assessment before the use of side rails. Staff interviews confirmed that such assessments were not completed, and the use of side rails was primarily for safety, balance, and as an enabler for bed mobility and transfers. Additionally, another resident was found with all four side rails raised without an assessment for the need, safety, or informed consent for the lower side rails. Staff interviews indicated that the use of all four side rails was not ordered or assessed, and that this practice could restrict the resident's movement and be considered a restraint. The facility's policies required alternatives to be tried, interdisciplinary evaluation, and informed consent before the use of bed rails, as well as regular reassessment, but these procedures were not consistently followed for the residents involved.
Failure to Rotate Insulin Injection Sites Results in Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors by not rotating subcutaneous insulin injection sites as required by physician orders, manufacturer guidelines, and professional standards. For three residents with diabetes, review of medical records and interviews with nursing staff revealed repeated administration of insulin in the same anatomical locations, despite clear orders and policies mandating site rotation. The electronic medication administration record system had the capability to track previous injection sites, yet staff did not utilize this feature to prevent repeated use of the same sites. One resident with type 2 diabetes and diabetic neuropathy received multiple insulin injections in the same abdominal quadrants over several weeks, as documented in the Location of Administration Report. Both the registered nurse and assistant director of nursing confirmed that this practice did not follow the physician's orders or facility policy, and acknowledged that it constituted a medication error. Similar findings were observed for two other residents, one with end-stage renal disease and metabolic encephalopathy, and another with severe cognitive impairment and total dependence for activities of daily living. In each case, insulin was administered repeatedly in the same areas, and staff interviews confirmed that site rotation was not performed as required. Facility policies and procedures, as well as manufacturer guidelines for both insulin aspart and insulin glargine, were reviewed and all specified the necessity of rotating injection sites to prevent adverse effects. The failure to rotate sites was consistently identified by nursing leadership and staff as a medication error, as it did not comply with physician orders, manufacturer instructions, or accepted professional standards. Documentation requirements for injection site assessment were also outlined in facility policy, but the records reviewed indicated non-compliance with these standards.
Deficiency in Drug Labeling and Secure Storage
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions and inactions resulted in a deficiency related to the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Inform of Arbitration Agreement Rights
Penalty
Summary
The facility failed to inform residents or their representatives of their choice to enter into a binding arbitration agreement and their right to refuse such an agreement. This deficiency occurred when the required information regarding the arbitration process and the option to decline participation was not communicated to the resident or their representative at the appropriate time.
Multiple Lapses in Infection Control and Environmental Cleanliness
Penalty
Summary
The facility failed to implement appropriate infection control practices in several key areas, as observed and documented by surveyors. In one instance, a shower room was found to be unclean, with feces, wound dressings, and a band-aid left on the floor and behind the curtain. Despite policies requiring daily cleaning and frequent visual checks, staff interviews revealed that the cleanliness of the shower room was not maintained, and this lapse was acknowledged by both the Housekeeping Director and the Assistant Director of Nursing as a risk for contamination and infection spread among residents. In the laundry area, two out of three dryer tumblers had torn door seal gaskets that were covered with tape, compromising the dryers' ability to reach and maintain proper temperatures. This issue was not reported to the Housekeeping Director until it was discovered during the survey, despite daily checks being part of the facility's maintenance protocol. The lack of timely reporting and repair of the equipment was recognized by staff as potentially leading to improperly dried linens, which could result in mold growth and increased infection risk. Additional deficiencies were observed in the use of personal protective equipment (PPE) and environmental cleanliness. One LPN failed to don gown and gloves when entering a resident's room under contact isolation for a multidrug-resistant organism, contrary to facility policy and posted signage. Another LPN did not wear a gown while repositioning a resident on Enhanced Barrier Precautions, despite clear orders and care plans requiring this for direct patient care. Furthermore, a shared bathroom trash can used by two residents was found to be dirty, stained, and possibly contaminated with feces, yet was not reported or replaced promptly by staff. These lapses in infection control practices were confirmed through interviews, observations, and review of facility policies.
Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for multiple residents, resulting in deficiencies related to medication management, use of medical devices, and environmental safety. For one resident prescribed PRN lorazepam for anxiety, there was no care plan addressing monitoring for side effects or behaviors associated with the medication, despite facility policy requiring such plans for psychotropic medications. Staff interviews confirmed that the absence of a care plan for monitoring could result in the resident not being properly observed for adverse effects or behavioral changes. Another resident using lower side rails per family request did not have a timely care plan developed to reflect this intervention. The care plan was created several days after the intervention was implemented, contrary to facility expectations that care plans be developed on the day of intervention. Observations and staff interviews revealed that the use of both upper and lower side rails was not always in accordance with orders, and the lack of a timely care plan could lead to staff not being aware of the correct interventions, potentially restricting the resident's movement or causing injury. Additional deficiencies included the failure to include the use of low air loss mattresses in the care plans of two residents at risk for pressure sores, despite physician orders and the presence of these devices in their rooms. Another resident prescribed Eliquis, an anticoagulant, did not have a care plan developed for its use after a medication change, leaving staff without guidance on monitoring for side effects. The facility also failed to implement a care plan intervention for a resident at risk of falls, resulting in a cluttered environment that impeded safe access to the restroom. Lastly, a resident with a history of elopement did not have an effective care plan in place, which resulted in the resident eloping from the facility. Staff interviews indicated a lack of awareness regarding the resident's elopement risk, and handoff communication did not consistently include this information.
Failure to Rotate Insulin Injection Sites and Inadequate Resident Supervision
Penalty
Summary
Licensed nursing staff failed to provide care in accordance with professional standards for multiple residents, specifically in the administration of insulin and the management of resident safety. For three residents with diabetes, staff did not rotate subcutaneous insulin injection sites as required by physician orders, facility policy, and manufacturer guidelines. Documentation and interviews confirmed repeated use of the same injection sites, despite the availability of electronic medication administration records that could track previous injection locations. Both the RN and ADON acknowledged that this practice was inconsistent with professional standards and could lead to complications such as skin irritation and poor insulin absorption. In addition to the insulin administration deficiencies, staff failed to adequately address the safety and supervision needs of a resident at risk for elopement, aspiration, and falls. The care plan for this resident did not include comprehensive, person-centered interventions for elopement risk, and staff did not provide the ordered supervision during meals. The resident was able to leave the facility unsupervised and experienced a fall upon return. There were also failures to monitor the resident's blood pressure as ordered, to implement the facility's monitoring policy requiring checks every two hours, and to conduct shift change endorsements at the bedside as required by facility policy. The report provides detailed evidence from record reviews, interviews with nursing staff, and policy documents, all confirming that the facility did not meet professional standards of quality in these areas. The deficiencies were observed across multiple residents and involved both medication administration and resident safety protocols, with staff and leadership acknowledging the lapses during interviews.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Nursing Staff Lacked Required Competencies
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of appropriate skills and knowledge among nursing staff, which impacted the quality of care provided to residents. There were no specific details provided about individual residents, their medical history, or their condition at the time of the deficiency. The report focuses on the general failure of staff to meet competency requirements necessary for resident care.
Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for multiple residents, as required by professional standards and facility policy. In one instance, a registered nurse did not document the physician's reply on the change of condition/SBAR form after a resident experienced an unwitnessed fall. Although the physician was notified and gave an order to hold the resident's anticoagulant for three days, this information was not recorded on the form. Both the nurse and the Director of Nursing confirmed that the physician's response should have been documented, regardless of whether new orders were given, to ensure all staff were aware of the interventions provided. In another case, a resident with a tracheostomy and dependence on a ventilator had missing documentation in the respiratory therapy electronic Medication Administration Record (eMAR) for two scheduled treatments. Both the registered nurse and the respiratory therapist acknowledged that the required documentation was not completed after the treatments, as mandated by physician orders and facility policy. The Director of Nursing also confirmed that all documentation should be completed prior to staff leaving the facility to ensure accuracy and continuity of care. Additionally, a certified nursing assistant inaccurately documented the amount of food a resident consumed during lunch, recording that the resident ate 50% of the meal without verifying the tray, when in fact the food was untouched. The same resident's blood pressure was not measured as ordered every six hours; instead, a licensed vocational nurse used a previous reading for a later time slot. Furthermore, the nurse documented zero crying spells for the resident, despite reports and observations that the resident had been crying throughout the day. These actions resulted in incomplete and inaccurate information in the residents' medical records.
Failure to Obtain Proper Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and able to understand their health status, care, and treatments, specifically regarding the use of psychotropic medications. For one resident with diagnoses including Alzheimer's disease, dementia, and mood disorder, the informed consent documented was for Depakene Oral Solution, while the actual physician's order and administration were for Depakote Oral Tablet Delayed Release. Staff interviews confirmed that the consent form did not match the medication preparation being administered, and a new consent was not obtained when the medication form was changed. This discrepancy was acknowledged by nursing staff, who stated that a new consent should have been obtained from the resident's representative to honor the resident's right to informed consent. For another resident with insomnia and depression, the facility failed to obtain informed consent from the resident or their responsible party prior to the administration of psychotropic medications, specifically citalopram and trazodone. The resident's responsible party reported not being contacted by the facility to discuss the risks, benefits, or alternatives to these medications before they were started. Facility documentation and staff interviews confirmed that there was no record of education or consent being provided prior to the initiation of these medications. Facility policies reviewed indicated that it is the responsibility of the attending healthcare practitioner to inform the resident or their representative about the initiation, reason for use, and risks associated with psychotropic medications, and that informed consent must be obtained prior to starting such medications. The failure to follow these policies resulted in residents or their representatives not being given the opportunity to make informed decisions regarding the use of psychotropic medications.
Failure to Provide Accessible and Accurate State Survey Agency Contact Information
Penalty
Summary
The facility failed to ensure that residents were properly informed of their right to file a complaint with the State Survey Agency, and did not provide visible, readable, and accurate contact information for the agency. During a Resident Council meeting, four out of five residents stated they did not know where the State Survey Agency contact information was posted and had not been made aware of where to find it. Observations confirmed that the required contact information was either missing or posted in a manner that was not easily readable, with incorrect address and telephone number details. The Activity Director acknowledged that the information was not accessible or accurate, and that it should have been provided during monthly council meetings. Further observation with the DON confirmed that the posted contact information was not visible, easily readable, or up to date, and that the residents' right to file a complaint with the State was not honored. Review of the facility's policy and procedure indicated that residents are to be informed about their rights, including the right to communicate with outside agencies. The deficiency was identified through direct observation, resident interviews, and review of facility policy.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved, are not provided in the report.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Prevent Unjustified Decline in ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The report specifically notes the lack of provision of adequate food and fluids necessary for the resident's health maintenance.
Failure to Maintain Safe Oxygen Tubing Practices
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care to a resident who required continuous oxygen therapy. During an observation, the resident's oxygen tubing via nasal cannula was found touching the floor, and the date on the tubing was illegible. Interviews with a CNA, RN, and the Assistant Director of Nursing confirmed that the tubing should not have been in contact with the floor due to infection control concerns, and that all staff were responsible for ensuring proper handling and labeling of the tubing. The facility's policy required oxygen tubing to be labeled with the date it was last changed, and for infection control practices to be followed to prevent the spread of infection. The resident involved had a history of sepsis, pneumonitis, and COPD, and was cognitively intact and able to make decisions regarding activities of daily living. Medical records indicated an order for oxygen administration via nasal cannula, with instructions to change the tubing as needed when soiled. Despite these orders and facility policies, the tubing was not properly maintained, leading to a deficiency in respiratory care and infection control practices.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Accurately Account for and Timely Administer Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring accurate accounting and administration of medications for two residents. In one instance, a discrepancy was found during an inspection of a medication cart, where the controlled drug record for oxycodone 10 mg indicated two doses remaining, but only one dose was present in the medication card for a resident. The registered nurse on duty admitted to administering the missing dose earlier in the day but failed to document it immediately on the controlled drug record, citing divided attention due to supervisory responsibilities. In another case, a resident with multiple diagnoses, including aphasia, dysphagia, hypertension, anxiety, depression, and a history of seizures, did not receive several scheduled medications on time. The medication administration audit revealed that five different medications, including atenolol, docusate sodium, Zoloft, Keppra, and clonazepam, were administered nearly four hours late. The licensed vocational nurse responsible for administering these medications confirmed the delay and acknowledged that such late administration could impact the resident's health, especially for medications related to blood pressure, seizures, and mental health. Interviews with both the nurse and the director of nursing confirmed that facility policy requires timely administration and documentation of medications, as well as necessary pre-administration monitoring such as checking vital signs. The director of nursing reviewed the medication administration record and confirmed the delay, noting that staff are required to document medication administration immediately after giving the medication, in accordance with facility policy.
Late Submission of Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete and submit a Quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident. The resident was originally admitted with diagnoses including urinary tract infection, generalized muscle weakness, and dysphagia, and was later readmitted. Review of the resident's records showed that the Quarterly MDS assessment had an Assessment Reference Date (ARD) of 4/24/2025 but was not submitted until 5/8/2025, which was the 93rd day, exceeding the 92-day requirement. The Director of MDS confirmed that the assessment was completed late and acknowledged the use of an MDS Scheduler to track due dates, which provides warnings for overdue assessments. Interviews with the Director of MDS and the Director of Nursing confirmed that timely completion and submission of MDS assessments are necessary for accurate quarterly reviews, care planning, and billing. Both staff members stated that late completion or submission of MDS assessments could result in delays in care, especially if there are significant changes in a resident's condition. Review of facility policy and the CMS Resident Assessment Instrument Manual confirmed the requirement for quarterly MDS assessments to be completed within 92 days of the previous assessment.
Late Submission of MDS Assessment Data
Penalty
Summary
The facility failed to ensure timely transmission of the Minimum Data Set (MDS) assessment data to the Centers for Medicare and Medicaid Services (CMS) for one resident. Specifically, the admission MDS for a resident with diagnoses including type 2 diabetes mellitus with foot ulcer, encephalopathy, and generalized muscle weakness was completed with an Assessment Reference Date (ARD) of 2/12/2025 but was not submitted to CMS until 2/26/2025, which was beyond the required 14-day timeframe. The Director of MDS confirmed that the assessment was submitted late and acknowledged that the MDS Scheduler is used to track due dates, and that the system provides warnings for overdue assessments. Interviews with the Director of MDS and the Director of Nursing confirmed that timely completion and submission of MDS assessments are necessary for accurate quarterly reviews, care planning, and billing. The facility's policy and procedures, as well as the CMS Resident Assessment Instrument Manual, require assessments to be completed and submitted within specific timeframes. The late submission of the MDS assessment was verified through review of the CMS Final Validation Reports and facility records.
Failure to Secure and Cover Feeding Tube Tip After Disconnection
Penalty
Summary
A deficiency occurred when staff failed to secure and cover the feeding tube tip with a cap after disconnecting it from a resident who was receiving enteral feeding. During an observation, the disconnected feeding tube tip was found lying on the floor, uncovered and exposed to the environment. The registered nurse present confirmed that the tube should have been covered with a cap and secured on the pump when not in use, in accordance with facility policy and best practices to prevent infection. The resident involved had a history of gastrostomy, dysphagia, tracheostomy, and traumatic brain injury, and was assessed as having severely impaired cognitive functioning, requiring total assistance with all activities of daily living. The care plan identified risks including infection at the gastrostomy tube site, and the physician's orders specified the use of tube feeding. Facility policy required that enteral feeding safety precautions be followed, including keeping the tube covered when not in use, but this was not done in this instance.
Failure to Implement Infection Prevention Policy Due to Mice Infestation
Penalty
Summary
The facility failed to implement its infection prevention policy by not preventing the presence of mice in residential rooms occupied by four residents. The deficiency was identified through interviews and record reviews, revealing that mice were found in rooms occupied by residents with various medical conditions, including hypertension, anxiety disorder, major depressive disorder, heart failure, and mobility issues. The presence of mice was reported by visitors and confirmed by the Maintenance Supervisor, who captured mice in the affected rooms. The facility's policies on pest control and infection prevention, last revised in 2008 and 2023 respectively, were not effectively implemented, as evidenced by the presence of mice. The Infection Control Nurse acknowledged that pests should not be inside the facility due to the potential for disease transmission. The facility's pest control policy states that the building should be kept free of insects and rodents, and the infection prevention program aims to maintain a safe and sanitary environment to prevent communicable diseases. However, the presence of mice indicates a failure to adhere to these policies.
Facility Fails to Prevent Mice Infestation in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment by allowing the presence of mice in residential rooms occupied by four residents. The deficiency was identified through interviews and record reviews, revealing that mice were found in rooms occupied by residents with various medical conditions, including hypertension, anxiety disorder, major depressive disorder, and heart failure. The presence of mice was confirmed by both staff and visitors, indicating a breach in maintaining a homelike environment. Interviews with facility staff, including a Certified Nurse Assistant and the Maintenance Supervisor, confirmed the presence of mice in the residents' rooms. The Maintenance Supervisor provided photographic evidence of mice captured in the rooms, further substantiating the issue. The Infection Control Nurse acknowledged that pests should not be present in the facility due to the potential health risks they pose, including the transmission of diseases. The facility's policies and procedures, including those related to pest control, maintenance, and infection prevention, were reviewed. These policies emphasize the importance of maintaining a pest-free environment to ensure the safety and well-being of residents, staff, and visitors. Despite these policies, the facility failed to prevent the infestation, leading to unsanitary and uncomfortable living conditions for the affected residents.
Deficient Pest Control Program Leads to Mice Infestation
Penalty
Summary
The facility failed to implement an effective pest control program, resulting in the presence of mice in residential rooms occupied by four residents. The deficiency was identified through interviews and record reviews, revealing that mice were found in rooms occupied by residents with various medical conditions, including hypertension, anxiety disorder, major depressive disorder, heart failure, and mobility issues. The presence of mice was confirmed by both staff and visitors, with photographic evidence provided by the Maintenance Supervisor. Interviews with facility staff, including a Certified Nurse Assistant, the Maintenance Supervisor, and the Infection Control Nurse, highlighted the issue of mice being caught in the facility. The Maintenance Supervisor confirmed the capture of multiple mice in the affected rooms, and the Infection Control Nurse emphasized the potential health risks posed by mice, such as disease transmission and property damage. The facility's pest control policy, last revised in 2008, stated the importance of maintaining a pest-free environment, but the presence of mice indicated a failure to adhere to this policy.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that pad call lights were within reach for three out of five sampled residents during random observations. Resident 3, who was non-verbal, non-communicative, and had severely impaired cognition, was observed with the pad call light placed on the left uppermost part of the bed, out of reach. The resident required total assistance with all activities of daily living and was at high risk for falls. The facility's policy indicated that call lights should be within reach, but this was not adhered to, as confirmed by the Registered Nurse and the Director of Nursing. Similarly, Resident 40, who had severely impaired cognition and required total assistance, was observed with the call light not within reach. The resident was unable to move, and the call light was placed on the left side of the bed, not touching any part of the resident's body. The facility's policy and care plan for Resident 40 also required the call light to be within reach, but this was not followed, as noted by the Registered Nurse and the Director of Nursing. Resident 89, who had severely impaired cognition and required total assistance, was also observed with the call light not within reach. The resident's call light was placed on the left side of the bed, and the resident could not move to reach it. The facility's policy and care plan for Resident 89 required the call light to be within reach, but this was not implemented. Additionally, Resident 19, who required substantial assistance and had mild cognitive impairment, was found with the call light attached to the far side of the bed, out of reach. The Certified Nursing Assistant confirmed that the call light should have been placed within reach, as per the facility's policy.
Deficiencies in Homelike Environment and Resident Care
Penalty
Summary
The facility failed to provide a homelike environment for several residents, leading to deficiencies in their care. For one resident, the bathroom flooring under the shower chair was in disrepair, causing instability and potential risk of injury. Despite the resident and a Licensed Vocational Nurse (LVN) identifying the issue, it was not reported to the Maintenance Supervisor in a timely manner, resulting in the flooring remaining broken and unsafe for use. Another deficiency involved two residents who were not provided with flat sheets on their pressure-reducing mattresses, leading to direct contact with the plastic mattress covers. This was against the facility's policy, which required a flat sheet to be placed over the mattress. The lack of a sheet was attributed to a misunderstanding of the facility's policy on layering, which limited the number of layers on the mattress to two, including incontinence briefs and pads. This oversight resulted in an uncomfortable and non-homelike environment for the residents. Additionally, the facility failed to maintain the cleanliness of a resident's desk fan, which was observed to be dusty. The housekeeping department was responsible for cleaning such equipment, but the fan had not been cleaned as part of the monthly deep cleaning schedule. This lack of cleanliness was noted to potentially affect the resident's dignity and quality of life, as well as pose an infection control risk.
Failure to Obtain Proper Authorization for Restraint Use
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment, as evidenced by the lack of physician's orders, assessments, and informed consents for the use of restraints on five residents. For Resident 37, pillows were placed under the mattress and bed rails were used without proper authorization or assessment, despite the resident's inability to make decisions and a history of attempting to jump out of bed. The facility's staff and family members were involved in placing these restraints, but no formal consent or assessment was documented. Resident 46, who was diagnosed with quadriplegia and other conditions, had all four side rails raised without a physician's order, consent, or assessment for bed entrapment. This was contrary to the facility's policy, which requires such documentation to ensure the safety and rights of the resident. Similarly, Resident 79 had all side rails raised without the necessary orders and consents, despite having a history of falls and expressing discomfort with the restraints. Resident 63 was found with bilateral hand mittens applied too tightly, contrary to the physician's order for a right hand mitten only. This improper application posed risks of poor circulation and skin breakdown. Lastly, Resident 73 had all four side rails raised, which was not in accordance with the physician's order for only bilateral upper half side rails. These deficiencies highlight the facility's failure to adhere to its own policies and procedures regarding the use of physical restraints, potentially compromising resident safety and dignity.
Failure to Rotate Injection Sites for Insulin and Anticoagulant Administration
Penalty
Summary
The facility failed to adhere to professional standards of care by not rotating subcutaneous injection sites for insulin and anticoagulant administration for several residents. This deficiency was identified during interviews and record reviews, revealing that insulin and anticoagulant injections were repeatedly administered in the same areas, contrary to the facility's policy and manufacturer guidelines. The failure to rotate injection sites was observed in four residents receiving insulin and one resident receiving anticoagulant therapy, increasing the risk of adverse effects such as lipodystrophy and bruising. Resident 61, who was admitted with type 2 diabetes mellitus and other conditions, had multiple instances where insulin was administered without site rotation, as confirmed by a review of the Location of Administration Report. Similarly, Resident 60, who was on insulin and anticoagulant therapy, also had instances of non-rotated injection sites. Interviews with the RN and DON confirmed that the licensed nurses did not follow the expected practice of rotating injection sites, which is crucial to prevent skin complications. Further review of the facility's policies and manufacturer guidelines emphasized the importance of rotating injection sites to prevent skin abnormalities. Despite these guidelines, the MARs for Residents 24, 43, and 85 showed multiple instances of non-rotated insulin administration sites. The DON acknowledged that the failure to rotate injection sites could lead to skin abnormalities, such as lumps or thickened skin, and confirmed that several licensed nurses did not adhere to the standard practice, placing the residents at risk of harm.
Facility Fails to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for seven residents. For Resident 89, the sensor pad alarm in bed was not functioning properly, as observed during a visit. The alarm was supposed to alert staff when the resident attempted to get up unassisted, but it did not activate due to being slightly folded. This malfunction was confirmed by a registered nurse, who noted that the alarm should have a blinking light to indicate proper function. The facility's policy required the alarm to be checked every shift, but this was not adhered to, putting the resident at risk of falls. Residents 25, 446, and 60 were found to have their beds in a high position when not receiving care, contrary to the facility's policy of keeping beds at the lowest position to prevent falls. Observations revealed that the beds were significantly higher than recommended, and staff acknowledged the risk of falls due to involuntary movements. Despite having care plans and physician orders to maintain low bed positions, these were not followed, increasing the risk of injury from falls. Additional hazards were identified for Residents 11, 19, and 42. Resident 11's oxygen concentrator and enteral feeding pole were placed on a fall mat, making them unstable and posing a risk of falling over the resident. Resident 19's wheelchair was left unattended on a fall mat, which could lead to instability and potential falls. Resident 42's bathroom flooring was in disrepair, causing instability for the shower chair, which could result in injury. These conditions were not addressed in a timely manner, despite being reported, indicating a failure to maintain a safe environment as per the facility's policies.
Deficiencies in Feeding Tube Management and Labeling
Penalty
Summary
The facility failed to ensure proper labeling and management of feeding tube equipment for several residents, leading to potential risks of altered nutritional status and complications. For Residents 84 and 60, the water flush bags were not labeled with the resident's name, infusion rate, and start date and time, which are necessary to ensure the correct hydration and prevent the use of expired equipment. Similarly, Resident 28's feeding bottle was not labeled with the start date and time, posing a risk of administering spoiled formula, which could lead to gastrointestinal issues. Additionally, the facility did not label the enteral feeding (EF) bottles and water flush bags for Residents 33 and 55 with the infusion rate as ordered by the physician. This oversight could result in the residents not receiving the correct amount of nutrition and hydration, potentially leading to dehydration and other health issues. The facility's policy requires that all EF bottles and water flush bags be labeled with the resident's name, start date and time, and infusion rate to ensure accuracy and safety. Furthermore, the facility failed to ensure that LVN 3 checked the placement of Resident 80's gastrostomy tube (GT) before starting the enteral feed. This omission could lead to serious complications, such as infection or improper administration of nutrition. The facility's policy mandates that GT placement be verified before each use to prevent such risks. The DON confirmed that LVN 3 did not adhere to this policy, which could have resulted in adverse outcomes for the resident.
Deficiencies in IV Fluid Administration and Documentation
Penalty
Summary
The facility failed to administer parenteral fluids consistent with professional standards of practice for two residents. For Resident 445, the facility did not ensure that the IV fluid infusing on the left upper arm midline was free from signs and symptoms of infiltration, such as redness and swelling. Additionally, the facility failed to document dressing changes for the right upper arm PICC line and the left upper arm midline in the Medication Administration Record (MAR) on specific dates. The facility also did not document the flushing of the PICC line and midline as ordered by the physician, which could lead to complications such as swelling and infection. Resident 445 was admitted with diagnoses including chronic respiratory failure, tracheostomy, and epilepsy, and had severely impaired cognition requiring total assistance with all activities of daily living. During an observation, the resident's IV site showed signs of infiltration, which was verified by a registered nurse. The nurse acknowledged the failure to document the dressing change and flushing of the injection ports, which are necessary to ensure the lines are patent and to prevent complications. For Resident 60, the facility did not clarify with the primary physician whether the peripheral IV catheter was still needed after the completion of IV antibiotics. The dressing of the peripheral IV catheter was not changed weekly as required, and a green cap was not placed on the flush port to prevent infection. Resident 60 was admitted with conditions including gastrostomy, tracheostomy, and acute embolism. The failure to follow proper procedures for IV care and maintenance exposed the resident to potential infection risks.
Failure to Properly Assess and Manage Bed Rails and Restraints
Penalty
Summary
The facility failed to properly assess and manage the use of bed rails and physical restraints for several residents, leading to potential safety risks. For Resident 46, who was admitted with conditions such as quadriplegia and seizures, the facility did not have a physician's order, informed consent, or an assessment for bed entrapment despite the use of all four side rails, which were considered a restraint. This oversight was confirmed during interviews with staff, who acknowledged the importance of having proper documentation and assessments to ensure resident safety and respect their rights. Resident 37, who was dependent on staff for activities of daily living and had a history of epilepsy, was found with pillows placed under the mattress to create an incline, which was considered a restraint. The facility did not perform an assessment for the use of these pillows or the bed rails, and staff confirmed that these measures were used to prevent the resident from jumping out of bed. The lack of assessment and informed consent for these interventions was acknowledged by the facility's staff, highlighting a failure to ensure the safety and appropriateness of the interventions. For Resident 73, who had chronic respiratory failure and epilepsy, the facility did not follow the physician's order for the use of bilateral upper half side rails, instead using all four side rails, which restricted the resident's movement. Although informed consent and an entrapment risk assessment were obtained for the use of the upper half side rails, the facility did not adhere to the specified order, resulting in the use of a restraint. This deviation from the physician's order was confirmed by staff, who recognized the importance of following prescribed interventions to ensure resident safety.
Failure to Implement Pharmacist Recommendations for Hospice Resident
Penalty
Summary
The facility failed to ensure that the consultant pharmacist's recommendations from the July 2024 Medication Regimen Review (MRR) were implemented for a resident enrolled in hospice care. The resident, who had diagnoses including Type 2 Diabetes Mellitus, Depression, and Psychosis, was prescribed Escitalopram for depression and Lispro insulin for high blood sugar. Despite the consultant pharmacist's recommendation to monitor the resident's blood sugar control with a HgA1C test and consider a dose reduction for Escitalopram, these actions were not taken. The attending physician disagreed with the recommendations, citing end-of-life comfort measures, but did not provide a documented clinical rationale or signature. The Director of Nursing (DON) confirmed during an interview that the resident's clinical record lacked an order to stop laboratory services and that no HgA1C level had been obtained in the last three months. The DON acknowledged that monitoring HgA1C levels is essential for managing the resident's diabetes and that the absence of such monitoring could lead to unnecessary medication use. Additionally, the resident had no documented behaviors of depression since January 2024, yet no attempt was made for a gradual dose reduction (GDR) of Escitalopram, nor was there documentation justifying the continuation of the medication without a GDR. The facility's policies and procedures require coordination with hospice care to ensure residents' needs are met and that medication regimens are reviewed to prevent adverse consequences. However, the facility did not adhere to these policies, as evidenced by the lack of documentation and follow-through on the consultant pharmacist's recommendations. This oversight placed the resident at risk of continuing unnecessary medications, including psychotropic drugs, without adequate monitoring or clinical justification.
Latest citations in California
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
