Stanley Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Westminster, California.
- Location
- 14102 Springdale Street, Westminster, California 92683
- CMS Provider Number
- 555651
- Inspections on file
- 20
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Stanley Healthcare Center during CMS and state inspections, most recent first.
The facility failed to have an RN onsite on the evening and night shifts to provide respiratory services for residents with oxygen orders. The staffing plan showed 0 RNs on those shifts, while LVNs were assigned instead. A resident with COPD and CHF had orders for continuous O2, oxygen saturation monitoring, and BiPAP at bedtime, and another resident with CHF had orders for continuous O2 and oxygen saturation checks. The DON confirmed LVNs could not adjust or titrate oxygen flow or concentration in non-emergent situations, yet no RN was available onsite during those shifts.
Unsanitary kitchen conditions were observed for food prepared for all residents using the facility kitchen. Surveyors found a hood over the stove with dirt residue, multiple damaged and deformed utensils, utensils and measuring cups with films and crusted residue, heavily marred cutting boards with deep grooves, and an unlabeled, undated white powder stored in a measuring cup. Facility policy and USDA Food Code standards cited in the report required clean, sanitary, and properly maintained food-contact surfaces and utensils.
The facility failed to carry out its infection surveillance program as written, because the IP only reviewed residents who were prescribed antimicrobials or diagnosed with an infection and did not include residents with signs and symptoms who were not treated or diagnosed, leaving no residents listed as not meeting McGeer's Criteria. Staff also stored a purse and jacket on the clean laundry sorting counter next to clean linens, and a resident had urinals with urine placed on the overbed table beside a water pitcher.
A resident with no capacity to understand and make decisions had orders for lorazepam, buspirone, citalopram, and bilateral one-half side rails. The medical record did not show informed consent for the lorazepam, buspirone, or side rails, and it also did not show an updated consent when the citalopram dose was increased. The DON confirmed the missing consents, and staff observed the resident in bed with the side rails elevated.
A resident receiving quetiapine for schizoaffective disorder had no documented orthostatic BP monitoring in the lying and sitting positions, despite a care plan and MD orders to monitor for orthostatic hypotension. The record also lacked documentation of the nonpharmacological interventions used during multiple episodes of bizarre delusions, and the DON confirmed the missing monitoring and documentation during the survey review.
A resident’s PASRR Level 1 Screening stated there was no diagnosed serious mental illness, but the medical record showed diagnoses of bipolar disorder and PTSD. During record review, the DON verified the PASRR information was incorrect.
A resident with capacity to understand and make decisions had a physician order for a foot cradle in bed to prevent skin breakdown, but surveyors observed no foot cradle in the room and a CNA verified it was not attached to the bed. The DON confirmed the order and stated the foot cradle was used for skin breakdown prevention, and the Administrator and DON acknowledged the findings.
A resident receiving dialysis had a left arm AV shunt and an order to check the access site each shift for bleeding and signs of infection. During observation, no dialysis emergency kit was available at the bedside, and an LVN confirmed the kit was needed if bleeding occurred at the access site. The DON stated the kit should always be available and accessible in the resident’s room.
Incomplete Bed Rail Assessments and Missing Least-Restrictive Intervention Review: The facility failed to ensure two residents with physician orders for bilateral one-half side rails had accurate bed rail assessments showing the reason for siderail use and documentation that less restrictive interventions were tried first. One resident was cognitively intact per BIMS, and the other had no capacity to understand and make decisions per H&P. The DON verified the missing assessment elements during interview and record review.
A resident with severe cognitive impairment did not have the required face-to-face physician visits documented at the expected interval. The facility’s records showed the last documented physician visit was months earlier, and the DON confirmed the resident should have been seen monthly.
A resident with schizophrenia and bizarre delusions had an order for Cobenfy 100-20 mg capsule PO BID, but the evening dose was not administered on two consecutive days because the medication was unavailable. MAR and administration notes documented the missed doses, and the DON verified the resident did not receive the medication as ordered.
Failure to follow a pharmacy MRR recommendation for a resident’s ibandronate order. The resident had no capacity to understand and make decisions, and the MAR showed the medication was given at 0600 hours even though the MRR recommended changing the administration time to 0500 hours. During interview, the DON verified the recommendation was missed, and the Administrator and DON acknowledged the finding.
Medication Error Rate Exceeded Threshold: The facility’s medication error rate was 8%, above the required limit. During a med pass for a resident with orders for cholecalciferol and fluticasone, an LPN verified that both meds were unavailable in the med cart and therefore were not administered as ordered. The DON stated that unavailable meds were to be obtained from central supply/pharmacy and given as soon as possible, or the physician notified and the reason documented if held.
Improper Storage of Treatment Supplies on Medication Cart: Surveyors observed Medication Cart A with one open pack of sterile gauze bandage roll and three open packs of single-use Medi strip reinforced wound closure. The DON confirmed the items were single use and stated open, unused pouches needed to be discarded to maintain sterility. The facility policy required nursing staff to keep storage and preparation areas clean, safe, and sanitary.
Improperly Closed Garbage Dumpster Lid: The facility failed to ensure one outside garbage dumpster was properly stored. The dumpster lid was observed partially propped open by garbage bags, preventing it from fully closing. The DSS reviewed a photo of the dumpster and confirmed the finding, stating the lid should be fully closed at all times to prevent rodents from entering or exiting the trash and for infection control purposes.
Incomplete and inaccurate resident records were identified for several residents. Side rail safety assessments did not match physician orders for three residents, one resident’s chart lacked signed informed consent for psychotropic meds, one resident’s BP was documented on the dialysis access arm despite orders not to use that arm, and one resident’s POLST was missing the physician signature and date. The DON verified the record discrepancies and missing documentation.
Inaccurate Daily Nursing PPD Posting: The facility failed to keep the daily nursing PPD posting current and accurate. Surveyors observed that the posting near the business office showed an outdated date and did not include the correct census or staffing data. The DSD confirmed that NOC or morning shift charge nurses were responsible for replacing the posting each day and acknowledged the finding.
The facility failed to verify the identity and CNA licensure of a registry staff member, allowing an unverified male individual to work a CNA shift under a female CNA’s name. The DSD/IP oriented this individual and had another CNA provide a brief resident-care orientation without checking a government ID, CNA license, or competency evaluation. The facility relied solely on the registry company to confirm identity and licensure and did not maintain personnel files or conduct its own verification for registry staff, resulting in an unidentified person providing direct care under another CNA’s credentials.
Surveyors found that the facility did not ensure safe and appropriate respiratory care for four residents, including missing physician orders for suctioning, improper storage of oxygen cannula tubing, failure to change nebulizer equipment as required, and lack of cleaning for CPAP components. These deficiencies were identified through direct observation, staff interviews, and review of medical records and facility policies.
The facility did not provide written information about bed-hold options to three residents or their responsible parties when they were transferred to an acute care hospital. Instead, an LVN only discussed the bed-hold option verbally and did not supply the required written documentation, as confirmed by both medical record review and staff interviews.
A resident with an indwelling urinary catheter did not have any physician's orders documented for the catheter's use, care, or maintenance. This was confirmed through medical record review and interviews with an LVN and the DON, who both acknowledged the absence of required orders despite the resident being observed with a urinary drainage bag.
A resident's annual and discharge return-anticipated MDS assessments were not completed within the required 14-day period after the ARD. Both assessments remained in progress well past the deadline, as confirmed by the DON during record review and interview.
A physician's order for wound care did not specify the location of a Stage 3 pressure ulcer for a resident. Medical records indicated the presence of the ulcer, but the order itself omitted this critical detail, which was confirmed by the DON during review.
Staff did not follow Enhanced Barrier Precautions when providing incontinence care to a resident with an indwelling urinary catheter. Despite facility policy and posted signage requiring both gloves and gowns for high-contact care, staff were observed wearing only gloves. The infection preventionist confirmed that proper PPE was not used as required.
The facility failed to maintain sanitary conditions in the kitchen, with a dirty microwave, residue on the stove hood, and damaged utensils. Utensils were partially melted, chipped, or discolored, and cutting boards were heavily marred. These deficiencies risked cross-contamination and foodborne illnesses, as acknowledged by the Dietary Supervisor.
The facility failed to follow infection control practices, including not notifying physicians when infections didn't meet criteria, not implementing contact isolation for a resident with C. difficile, and using non-cleanable equipment. Additionally, staff did not adhere to Enhanced Barrier Precautions for residents at risk of MDRO transmission.
A facility failed to meet professional standards of care when an LVN improperly obtained a resident's blood pressure by placing the cuff and stethoscope over the resident's clothing instead of directly on the skin. This was contrary to the facility's policy, which requires direct skin contact for accurate readings. The LVN and other staff confirmed the correct procedure during interviews.
A resident with limited mobility and ROM functions did not receive the necessary treatment and services to maintain or improve her ROM. Despite the care plan indicating daily ROM exercises, there was no documentation of these exercises being provided. Interviews with facility staff confirmed the lack of ROM exercises, and the resident had not been evaluated for physical therapy. This failure had the potential to cause a decline in the resident's physical abilities.
A facility failed to complete a smoking assessment for a resident upon admission, as required by their policy. Despite the resident being supervised while smoking, the necessary assessment was not documented in the medical record. This oversight was confirmed by an LVN and acknowledged by the DON, posing a potential risk for accidents or injuries.
The facility failed to follow physician's orders for oxygen therapy for two residents. One resident received oxygen at a higher rate than prescribed, while another was not using the prescribed continuous oxygen therapy. The discrepancies were confirmed by staff, and the residents' oxygen saturation levels were affected.
The facility failed to ensure proper use and documentation of side rails for four residents, leading to potential accident hazards. A resident's informed consent was incomplete, another's care plan lacked side rail use details, and assessments were missing for two residents. These deficiencies were confirmed by the DSD/IP.
A facility failed to ensure proper pharmaceutical services when an LVN administered laxatives to a resident without assessing bowel status or reviewing medical records, contrary to physician orders. The resident, unable to make medical decisions, had specific orders to hold laxatives for loose stool, which were not followed. The LVN admitted to not checking the resident's bowel status, and the Administrator and DON acknowledged the deficiency.
The facility failed to address the Pharmacy Consultant's recommendations for two residents, risking adverse medication consequences. One resident's recommendations for Preparation H and Benadryl were not documented as addressed, while another resident's lorazepam order lacked a required stop date evaluation. Despite claims of physician contact, no evidence was found in the medical records.
Two LVNs at the facility were observed making medication administration errors, resulting in a medication error rate of 11.11%. One LVN incorrectly reconstituted polyethylene glycol for a resident, while another LVN made the same error and failed to administer a vitamin B12 supplement to another resident. The errors were acknowledged by the LVNs and the DON.
The facility failed to ensure proper documentation and care plans for two residents receiving hospice services. A resident's hospice visit calendar and updated care plan were missing, while another resident lacked a care plan and visit schedule. Staff confirmed these deficiencies, posing risks to hospice care coordination.
The facility failed to implement QAPI action plans to monitor the effectiveness of pharmacy consultant recommendations, as required by their POC. The DON did not assign the charge nurse to review and address the DRR, resulting in a lack of follow-up and communication with the physician. This oversight violated the facility's POC and had the potential to affect the quality of care for all residents.
The facility failed to ensure a glucometer was maintained in safe operating condition. Quality control records for February and March 2025 did not match the glucometer's saved results, with several documented results missing from the device's memory. This issue was verified by an LVN and acknowledged by the DON.
The facility failed to accurately complete entrapment assessments for four residents, leading to potential safety risks. Observations showed discrepancies in bed measurements, confirmed by the Maintenance Supervisor and acknowledged by the Administrator. Residents with elevated side rails for mobility assistance had inaccurate bed measurements, increasing the risk of entrapment.
A facility failed to update a resident's POLST and obtain a copy of their advance directive. Despite the resident's family executing an advance directive, the POLST did not reflect this, and the facility did not follow up to obtain the document. The Social Services/Activities Director confirmed these findings during an interview.
The facility failed to provide timely written notification of transfer or discharge to two residents and their representatives, as well as to the LTC Ombudsman. One resident was transferred to a hospital due to a possible G-tube issue without proper notification, and another was discharged home without notifying the Ombudsman. Staff confirmed the lack of documentation for these notifications.
The facility failed to complete and transmit the MDS for discharge for a resident who was readmitted after an acute care hospital stay. The oversight was confirmed during an interview with the Administrator.
A facility failed to accurately code the MDS for a resident's RNA services, leaving Section O blank despite existing physician's orders for orthosis and range of motion exercises. The MDS Coordinator lacked access to the EHR, leading to the omission, which was confirmed by the DSD/IP. This posed a risk of the resident not receiving a tailored care plan.
The facility failed to revise the care plan for a resident with moderately impaired cognition after the resident reported an abuse allegation against a CNA. Interviews confirmed that no new or revised care plan was created following the incident, despite facility policies requiring updates to care plans to address identified problems and risk factors.
No RN Onsite for Evening and Night Respiratory Services
Penalty
Summary
The facility failed to ensure that a staff member was onsite during the evening and night shift who could provide respiratory services to residents in accordance with their plans of care. The report states that for the past year, the facility did not have an RN assigned to the evening or night shift, and LVNs were the nurses on site during those shifts. The California Code of Regulations review showed that LVNs may not perform certain respiratory services, including the initial setup, change out, or replacement of a breathing circuit or adjustment of oxygen liter flow or oxygen concentration. The facility assessment identified that the facility cared for residents with respiratory conditions including COPD, pneumonia, asthma, chronic lung disease, and respiratory failure, and that an average of six residents received oxygen therapy. The staffing plan listed 1 RN on day shift and 0 RNs on both evening and night shifts. The facility’s oxygen administration policy described oxygen therapy procedures and required review of physician orders and care plans before administration. Resident 27 had diagnoses of COPD and CHF, with orders for continuous oxygen at 2 LPM via nasal cannula, oxygen saturation monitoring every shift, and BiPAP at bedtime. During observation, Resident 27 was receiving continuous oxygen and stated that staff applied BiPAP at night and then set up the oxygen concentrator in the morning. The DON confirmed that LVNs worked the evening and night shifts, that LVN respiratory tasks did not include adjustment or titration of oxygen liter flow or concentration in non-emergent situations, and that no RN was onsite during those shifts to provide the respiratory services needed for residents with oxygen titration orders. Resident 5 had CHF and active orders for continuous oxygen at 2 LPM via nasal cannula and oxygen saturation monitoring every shift. Her oxygen saturation records showed intermittent administration of supplemental oxygen on evening and night shifts, with periods when she was on room air and later placed on oxygen. The DON verified that Resident 5 intermittently received supplemental oxygen therapy during the evening and night shifts and confirmed that LVNs could not adjust or titrate oxygen liter flow or concentration, while no RN was onsite during those shifts.
Unsanitary kitchen conditions and improperly maintained food-contact items
Penalty
Summary
The kitchen was found to be unsanitary during a survey observation and interview, affecting food prepared for 27 of 27 residents who consumed meals from the facility kitchen. During the initial kitchen tour, the hood over the stove was observed with black dirt residue. The kitchen staff member acknowledged the condition and stated the hood was cleaned weekly and also by an outside company, while the hood sticker showed the last service date as 10/27/25. Facility policy required hoods to be cleaned every two weeks and kept free of dust and grease. The surveyor also observed multiple kitchen utensils and food-contact items that were not in good repair or clean condition. Items included stainless steel scoops with uneven edges, partial melting, cracking, and deformation; a whisk with a deformed shape; a rubber spatula with chipped, cracked, and discolored edges; a bent dough cutter; and a cutting board with sticky white residue. Additional utensils were observed with fuzzy films, dry water marks, and crusted residue, including scoops, spoons, a spatula, and measuring cups. Facility policy required utensils, counters, shelves, and equipment to be kept clean and in good repair, and USDA Food Code standards cited in the report required food-contact surfaces and utensils to be clean and maintained in a state of repair. The surveyor further observed yellow and blue cutting boards that were fuzzy, heavily marred, and had deep grooves. The facility’s sanitation policy required separate chopping boards for meats and vegetables and for them to be thoroughly cleaned and sanitized after each use. In addition, an unlabeled and undated white powder was found stored inside a plastic measuring cup on a countertop shelf. The staff member identified it as a food thickener and stated it should have been labeled and dated. The DSS acknowledged the findings and stated the damaged utensils should have been discarded, the dirty utensils should have been rewashed and sanitized, the cutting boards should have been replaced, and the food thickener should have been labeled and dated.
Infection Surveillance and Cleanliness Failures
Penalty
Summary
The facility failed to implement its infection prevention and control program in accordance with its policy for surveillance of infections. The policy stated the Infection Preventionist would conduct ongoing surveillance for healthcare-associated infections and other significant infections, and nursing staff would monitor residents for signs and symptoms that may suggest infection according to current criteria and definitions. During interview and record review, the Infection Preventionist stated residents were only evaluated for McGeer's Criteria when they had signs and symptoms of infection and were prescribed an antimicrobial medication, or when they were diagnosed with an infection. Review of the Infection Surveillance Monthly Reports from May 2025 through February 2026 showed only residents classified as having healthcare-associated infections or community-acquired infections, with no residents listed as not meeting McGeer's Criteria. The Infection Prevention and Control Surveillance logs did not show any residents who exhibited signs and symptoms of infection but were not prescribed antimicrobial medications or not diagnosed with an infection. The Infection Preventionist verified that no resident had been classified as not meeting McGeer's Criteria during that period and stated the facility did not initiate the McGeer's Criteria form for residents who had signs and symptoms of infection but were not prescribed antimicrobial medications or were not diagnosed with an infection. The facility also failed to maintain infection control practices in other observed areas. In the laundry room, the counter designated for clean laundry sorting had a staff member's purse and jacket lying on it next to clean linens, and the staff member verified the items should not have been stored there for infection control. In Resident 24's room, the resident was observed awake and lying in bed with urinals containing urine on the overbed table next to the resident's water pitcher. Resident 24 stated he was waiting for the CNA to empty the urinals, and both the CNA and DON stated the urinals should not have been placed on top of the overbed table.
Failure to Obtain Informed Consent for Psychotropic Medications and Side Rails
Penalty
Summary
The facility failed to obtain informed consent for the use of lorazepam, buspirone, and bilateral one-half side rails for a resident who had no capacity to understand and make decisions, as documented in the resident’s H&P examination dated 10/26/25. The resident was admitted to the facility and later readmitted, and the physician’s orders included lorazepam 0.5 mg every Tuesday and Friday for anxiety manifested by aggression on shower days, citalopram 10 mg for depression manifested by crying and sad facial features, buspirone 15 mg twice daily for anxiety manifested by persistent screaming, and bilateral one-half side rails for mobility and repositioning. Review of the medical record showed no informed consents for the lorazepam, buspirone, or bilateral side rail use. The record also did not show an updated informed consent when citalopram was increased from 10 mg once daily to 10 mg every morning and at bedtime. During observation, the resident was seen lying in bed with the bilateral one-half side rails elevated, and a CNA stated the resident used the side rails to hold during diaper changes. The DON confirmed that the informed consents for the psychotropic medications and side rails were not obtained and acknowledged the findings.
Failure to Monitor Psychotropic Medication Effects and Document Nonpharmacological Interventions
Penalty
Summary
The facility failed to ensure that Resident 3 was free from unnecessary psychotropic medication use related to quetiapine. Resident 3 was admitted and later readmitted to the facility, had a quarterly MDS showing a BIMS score of 14, and had a care plan for quetiapine use related to schizoaffective disorder. The care plan included monitoring for orthostatic hypotension by checking blood pressure while lying and sitting and notifying the MD if there was a drop of 20 mmHg or more systolic or 10 mmHg diastolic every Monday day shift. The physician’s orders also included quetiapine 100 mg in the morning and 200 mg in the evening for schizoaffective disorder as manifested by bizarre delusions, along with orders to offer calm redirection, help identify triggers and measures that relieve fear, and set goals every shift. Review of the MARs for March and April 2026 failed to show that orthostatic blood pressure in the lying and sitting positions was monitored. The medical record also failed to show what nonpharmacological interventions were attempted when Resident 3 had episodes of bizarre delusions on multiple dates and shifts, including several day and evening shift episodes from 4/2/26 through 4/7/26. During an interview and concurrent record review, the DON stated that orthostatic hypotension monitoring should have included systolic and diastolic readings in the lying and sitting positions and verified that the licensed nurse should have documented what nonpharmacological interventions were used. The Administrator and DON were later informed of and acknowledged the findings.
Inaccurate PASRR Level 1 Screening for Mental Health History
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was inaccurate for one resident with a documented mental health history. Resident 4’s PASRR Level 1 Screening dated 1/13/25 indicated that the resident had no diagnosed serious mental illness, but the medical record also included a neuropsychiatric assessment showing diagnoses of bipolar disorder and PTSD. During an interview and concurrent record review, the DON reviewed the record and verified that the PASRR Level 1 Screening information was incorrect because it did not reflect the resident’s bipolar disorder and PTSD.
Failure to Apply Ordered Foot Cradle
Penalty
Summary
The facility failed to provide the necessary care and services to ensure Resident 8 attained and maintained the highest practicable physical well-being by not applying the ordered foot cradle in bed to prevent skin breakdown. Resident 8 was admitted to the facility and had a physician's order dated 7/13/24 for a foot cradle in bed. The resident's H&P dated 6/15/25 indicated the resident had the capacity to understand and make decisions. During an initial tour on 4/6/26, Resident 8 was observed awake and lying in bed, and no foot cradle was present in the room. On 4/9/26, a CNA verified there was no foot cradle attached to the bed, and the DON confirmed that the foot cradle was intended to prevent skin breakdown for Resident 8. The Administrator and DON were informed of and acknowledged these findings.
Dialysis Emergency Kit Not Available at Bedside
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was cited after the facility failed to ensure a dialysis emergency kit was available at the bedside for a resident receiving dialysis. Resident 8 had a physician’s order to check the dialysis site for bleeding and signs or symptoms of infection every shift and had a left arm AV shunt for dialysis access. The resident was observed awake in bed with the AV shunt and stated he went to dialysis every Tuesday and Saturday. During the initial tour, the resident’s room was observed and no dialysis emergency kit was available at the bedside. An LVN verified that the kit was needed to use if there was bleeding at the dialysis site. The DON stated that residents receiving dialysis should always be checked for bleeding at the access site and that the dialysis emergency kit should always be available and accessible in the resident’s room for any complications observed in the dialysis access site.
Incomplete Bed Rail Assessments and Missing Least-Restrictive Intervention Review
Penalty
Summary
The facility failed to ensure that two sampled residents, Residents 2 and 6, remained free from accident hazards associated with elevated side rails. The facility's policy on Proper Use of Side Rails stated that side rails should be used safely, that the space between the mattress and siderails should be assessed to reduce entrapment risk, and that less restrictive interventions should be documented before considering siderails. The report states that the facility failed to ensure the side rails assessment was accurate or completed, and/or that the least restrictive measures were provided prior to the use of the side rails for these residents. For Resident 2, the medical record showed a physician's order for bilateral one-half side rails for mobility and repositioning, but the bed rail assessment did not show the reason siderails were needed or that less restrictive interventions had been tried first. Resident 2's MDS quarterly assessment showed a BIMS score of 15, indicating the resident was cognitively intact. For Resident 6, the medical record also showed a physician's order for bilateral one-half side rails for mobility and repositioning, but the bed rail assessment did not show the reason siderails were needed or that less restrictive interventions had been tried first. Resident 6's H&P stated the resident had no capacity to understand and make decisions. During interviews and record review, the DON verified these findings for both residents, and the Administrator and DON were informed and acknowledged the findings.
Missed Required Physician Visits
Penalty
Summary
The facility failed to ensure that Resident 15 was seen by the physician at the required intervals. The facility’s Physician Visits policy stated that the attending physician must visit residents at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, unless an alternate schedule not exceeding 60 days is established. Resident 15 was admitted to the facility and had a quarterly MDS assessment showing a BIMS score of 3, indicating severe cognitive impairment. Review of Resident 15’s physician visit notes did not show documented evidence of the required physician visits between January and April 2026. During a concurrent interview and medical record review, the DON verified that the last documented face-to-face physician visit for Resident 15 was on 12/30/25 and stated there should have been a monthly physician visit. The Administrator and DON were later informed of and acknowledged the findings.
Medication Unavailable for Ordered Doses
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure the availability of a prescribed medication for one resident. Resident 5 had a physician’s order dated 2/20/26 for Cobenfy 100-20 mg capsule by mouth twice daily at 0900 and 1700 hours for schizophrenia manifested by bizarre delusions. The facility’s medication administration policy stated medications are to be administered in a safe and timely manner and in accordance with prescriber orders, including any required time frame. Review of the MAR showed the evening dose of Cobenfy was not administered on 3/28/26 and 3/29/26 at 1700 hours. Administration notes documented that on both occasions the medication was not given because it was unavailable, and the physician and pharmacy were informed. Further documentation indicated the pharmacy reported the medication was on order. During interview and concurrent record review, the DON verified the resident did not receive the ordered Cobenfy on those two evenings and stated the medication should have been available to be administered as ordered.
Failure to Follow Pharmacy Recommendation for Ibandronate Administration
Penalty
Summary
The facility failed to follow up on a pharmacy consultant’s monthly drug regimen review recommendation for one of five sampled residents reviewed for unnecessary medications. Resident 6, who had been admitted and later readmitted to the facility and whose H&P dated 10/26/25 stated the resident had no capacity to understand and make decisions, had a physician order for ibandronate 150 mg once monthly on every 28th day, to be given with eight ounces of water and with the resident remaining upright for at least one hour after administration. The March 2026 MAR showed the ibandronate was administered on 3/28/26 at 0600 hours, and the March 2026 MRR included a pharmacy recommendation to change the ibandronate administration time from 0600 hours to 0500 hours. During interview and concurrent record review on 4/9/26, the DON verified the recommendation had not been followed and stated she missed the recommendation. The Administrator and DON were informed of and acknowledged these findings.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent; the observed rate was 8 percent. During a medication administration observation for Resident 4, LVN 2 prepared and administered multiple scheduled medications, including Abilify, docusate sodium, finasteride, vitamin B-12, Keppra, potassium chloride, lacosamide, ClearLax, and Refresh Liquigel. Resident 4’s medical record showed active physician orders for cholecalciferol 125 mcg daily and fluticasone nasal spray 50 mcg, one spray in both nostrils twice daily. During a concurrent interview and record review, LVN 2 verified that cholecalciferol and fluticasone were not available for administration at the time of the medication pass. The DON stated that when a medication was not available in the medication cart, licensed nurses were expected to follow up with central supply or pharmacy to obtain it and administer it as soon as possible, and if the medication was held, the nurse was expected to inform the physician and document the reason in the progress notes. The Administrator and DON were informed of these findings and acknowledged them.
Improper Storage of Treatment Supplies on Medication Cart
Penalty
Summary
The facility failed to provide the necessary pharmacy services to ensure proper storage of medications for one of three medication carts inspected, identified as Medication Cart A. During an observation with the DON, surveyors found one individual pack of sterile gauze bandage roll open even though the package description indicated it contained sterile contents in an unopened, undamaged package, and three individual packs of Medi strip reinforced wound closure open even though the package description indicated they were single-use dressings. The facility's policy titled Storage of Medication Labeling and Storage, revised 2/2023, stated that nursing staff are responsible for maintaining storage and preparation areas in a clean, safe, and sanitary manner. During the observation and interview, the DON stated the individual pack was single use only and that all open and unused pouches needed to be discarded to maintain sterility, and the DON verified the findings. The Administrator and DON were later informed of and acknowledged the findings.
Improperly Closed Garbage Dumpster Lid
Penalty
Summary
The facility failed to ensure garbage was properly stored in one outside garbage dumpster. Review of the facility policy titled "Miscellaneous Areas, Garbage and Trash" dated 2023 showed garbage and trash cans must be inspected daily to ensure no debris is on the ground or surrounding area and that lids are closed. The 2022 FDA Food Code also states outside garbage receptacles must have tight-fitting lids or covers to prevent scattering of garbage or refuse, breeding of flies, or entry of rodents. During observation on 4/6/26 at 0740 hours, the outside garbage dumpster was seen with the lid partially propped open by garbage bags, which prevented the lid from fully closing. During interview on 4/6/26 at 1529 hours, the DSS reviewed a photograph of the dumpster and verified the finding, stating the lid should be fully closed at all times to prevent rodents from entering or exiting the trash and for infection control purposes.
Incomplete and Inaccurate Resident Medical Records
Penalty
Summary
Medical records were not complete and accurately documented for four sampled residents. The facility failed to maintain accurate side rail safety assessments for Residents 2, 6, and 11 in accordance with physician orders. Resident 2 had a BIMS score of 15 and a physician order for bilateral one-half side rails for mobility and repositioning, but the safety assessment in the record was for a one-fourth side rail. Resident 6 and Resident 11 each had physician orders for bilateral one-half side rails while in bed, but their safety assessments also reflected a one-fourth side rail. During observation, Resident 2 was seen in bed without the bilateral one-half side rails elevated, while Residents 6 and 11 were observed in bed with bilateral one-half side rails elevated. Resident 6’s record was also missing informed consent documentation for psychotropic medications. The resident’s H&P stated the resident did not have the capacity to understand and make decisions. The physician orders included citalopram for depression and buspirone for anxiety, but the medical record did not contain the signed informed consent forms for either medication. The DON reviewed the record and verified that the informed consents were not accessible in the chart. Resident 8’s medical record contained inaccurate blood pressure documentation related to a left arm dialysis access site. The resident had a left arm shunt for dialysis, and the care plan directed staff not to draw blood or take blood pressure on the left arm. However, the record showed multiple blood pressure readings documented on the left arm in March and April 2026. Resident 8 stated he never allowed nurses to take his blood pressure on the left upper arm, and the DON verified the documented readings were inaccurate. Resident 11’s POLST was also incomplete because Section D, Information and Signatures, did not include the physician’s signature or date, and the DON verified those blanks in the form.
Inaccurate Daily Nursing PPD Posting
Penalty
Summary
The facility failed to ensure the daily nursing PPD posting was accurate and up to date. During observation on 4/7/26 at 0940 hours, surveyors found the daily nursing PPD posting near the business office displayed a date of 3/31/26 and did not show the correct date, census, or staffing data. The report states the facility was responsible for posting the daily nursing PPD every day, and the DSD later confirmed that the NOC or morning shift charge nurses were responsible for removing the old projection and replacing it with the new projection each day. The DSD also stated the posting was important because the facility had frequent admissions and discharges and to ensure the facility was not over or understaffed.
Unverified Registry CNA Worked Under Another Individual’s Identity
Penalty
Summary
The facility failed to ensure that an individual working as a CNA held a valid and up-to-date license and met competency evaluation requirements for training. A complaint forwarded to CDPH indicated that a CNA from a registry was scheduled for an afternoon shift, but a male individual arrived and claimed to be that CNA, even though the actual CNA was a female. The male individual signed the staffing assignment sheet, received facility orientation from the DSD/IP, and then received a brief resident-care orientation from another CNA. The DSD/IP did not check or verify the individual’s identity using a government-issued ID or confirm the CNA license prior to or at the start of the shift. Interviews with the DSD/IP, DON, and Administrator revealed that the DSD/IP was responsible for verifying employees’ identity and licenses, conducting background checks, and providing orientations, but she did not verify the identity, license, certification, or competency evaluations of this individual or any registry staff prior to the incident. The Administrator stated that the facility relied on the registry company to verify identity and licensure and did not require its own verification of registry staff. The DSD/IP acknowledged she did not know whether the male individual who worked the shift had a valid CNA license or competency evaluation and that, prior to this event, the facility did not maintain personnel files or conduct identity and license checks for registry staff. The facility’s failure to verify the identity and licensure of the individual resulted in an unverified, potentially unlicensed person working under another CNA’s name and providing direct care to residents, with the DSD/IP later learning from the actual CNA that she had not accepted or worked the shift.
Failure to Provide Safe and Appropriate Respiratory Care and Infection Control
Penalty
Summary
The facility failed to provide necessary and appropriate respiratory care and services for four residents, as evidenced by multiple deficiencies in following physician orders and facility policies. For one resident, there was no physician's order for suctioning, despite the presence of a suction machine and care plan interventions that required suctioning if secretions could not be cleared. The suction equipment was observed to have fluid residue and was not properly labeled or changed according to policy. Another resident's oxygen nasal cannula tubing was not stored in accordance with facility policy, as part of the tubing was left out of the storage bag and was touching the floor, creating an infection control concern. The resident's care plan also did not address the use of oxygen, despite an active physician's order for PRN oxygen administration. A third resident's nebulizer administration set-up was not changed every seven days as required by facility policy, and the storage bag for the nebulizer tubing was not labeled with the resident's name. For a fourth resident, there was no documentation that the CPAP machine's washable filter, mask, nasal pillows, and tubing were cleaned according to the manufacturer's guidelines and facility policy during the resident's stay. These failures were confirmed through observation, interviews with staff, and review of medical records and facility policies.
Failure to Provide Written Bed-Hold Information Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written information regarding bed-hold options to residents or their responsible parties upon transfer to an acute care hospital, as required by facility policy. For three sampled residents who were transferred to the hospital, medical record reviews showed no documentation that written bed-hold information was given. The facility's policy specifies that prior to transfer, residents and their representatives must receive detailed written information about bed-hold rights, payment policies, and per diem rates for holding a bed beyond the state's bed-hold period. The Bedhold Notification Upon Transfer form, which is intended to document this process, was not found in the records of the affected residents. Interviews with the LVN responsible for the residents during their transfers revealed that while the nurse obtained physician orders for bed-holds and verbally asked residents or their responsible parties if they wanted a bed-hold, no written information was provided. The LVN was unaware of the specifics regarding bed-hold payments and only discussed the option verbally. The facility administrator confirmed that all residents should be offered written information about bed-hold options upon transfer, but this was not done for the residents in question.
Lack of Physician Orders for Indwelling Urinary Catheter
Penalty
Summary
A deficiency was identified when a resident admitted with an indwelling urinary catheter did not have any physician's orders documented for the use, care, or maintenance of the catheter. During medical record review, it was confirmed that there were no orders present for the indwelling urinary catheter, despite the resident being observed with a urinary drainage bag in place. An LVN verified the absence of these orders and stated that catheter care should be performed every shift and documented in the Treatment Administration Record (TAR). The Director of Nursing also acknowledged that the resident was admitted with the catheter and confirmed the lack of corresponding physician's orders.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete both the annual and discharge return-anticipated Minimum Data Set (MDS) assessments for a long-term resident within the required 14 calendar days after the Assessment Reference Date (ARD). Specifically, the annual MDS assessment had an ARD of 4/25/25 and remained incomplete 21 days after the ARD, while the discharge return-anticipated MDS assessment had an ARD of 4/29/25 and was incomplete 17 days after the ARD. The resident had been readmitted to the facility and was later transferred to an acute care hospital with the expectation of returning. The Director of Nursing confirmed that these assessments were overdue and should have been completed within the mandated timeframe.
Incomplete Wound Care Order Documentation
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurately maintained. Specifically, a physician's order for wound care did not include the location of the wound. Medical record review showed that the resident had a Stage 3 pressure ulcer to the medial sacrum, but the corresponding physician's order for wound care omitted this location detail. During an interview and concurrent record review, the DON confirmed that the wound care order lacked the required wound location information.
Failure to Follow Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
Facility staff failed to maintain infection control practices for a resident with an indwelling urinary catheter during incontinence care. According to the facility's Enhanced Barrier Precautions (EBP) policy, gloves and gowns are required for high-contact care activities, including hygiene and changing briefs, to reduce the spread of multi-drug-resistant organisms. During an observation, staff were seen providing incontinence care to the resident while wearing only gloves, despite EBP signage indicating the need for both gloves and gowns. The Director of Staff Development/Infection Preventionist confirmed that the staff should have been wearing isolation gowns in addition to gloves during this care activity. The resident involved had an indwelling urinary catheter and was under EBP due to this condition. The failure to follow established EBP protocols was verified through direct observation and staff interview, as well as a review of facility policy.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by several observations during a kitchen tour. The microwave used for warming food was found to be dirty with white crumbs on the glass plate. Additionally, the hood over the stove was observed to have black, dirt residue, despite the facility's policy requiring it to be cleaned every two weeks. The last service sticker on the hood indicated it was last cleaned in October 2024, suggesting a lapse in regular maintenance. The facility also failed to ensure that kitchen utensils and equipment were in good condition and clean. Several utensils, including slotted scoops, spatulas, and tongs, were found to be partially melted, chipped, or discolored. A basting brush had frayed bristles, and a cheese grater was cracked and chipped. These items were not replaced as required by the facility's policy, which mandates that unsanitary or hazardous items be discarded. The presence of these damaged utensils posed a risk of cross-contamination and foodborne illnesses. Furthermore, the facility did not maintain clean food-contact surfaces, as evidenced by utensils with dry water spots, fuzzy film, and crusted residue. Cutting boards were heavily marred with deep grooves, making them difficult to clean and sanitize. The Dietary Supervisor acknowledged these findings, confirming that the dirty utensils should have been sanitized, and the cutting boards replaced every three months to prevent bacterial growth. These deficiencies highlight a failure to adhere to professional standards for food safety and sanitation, potentially compromising the health of the residents consuming food prepared in the facility's kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control practices, as evidenced by several deficiencies in their infection prevention and control program. Physicians were not notified when infections in residents did not meet McGeer's criteria, affecting residents 2, 6, 9, 18, and 22. Additionally, Resident 627, who was diagnosed with a Clostridium difficile infection, did not have contact isolation precautions in place, and their infection was not accurately documented in the Infection & Control Surveillance Log for February 2025. The facility's Director of Staff Development/Infection Preventionist (DSD/IP) confirmed these oversights during a review of the facility's infection control documentation. The facility also failed to ensure proper cleaning and disinfection of equipment. Observations revealed that Licensed Vocational Nurses (LVNs) used a blood pressure wrist machine with a Velcro and cloth material closure, which was not suitable for disinfection with the facility's germicidal wipes intended for non-porous surfaces. This practice was acknowledged as inappropriate by the LVNs involved, as the equipment's material was not cleanable, posing an infection control issue. Furthermore, the facility did not consistently implement Enhanced Barrier Precautions (EBP) for residents at risk of multidrug-resistant organism (MDRO) transmission. A hospice LVN failed to wear a gown while providing wound care to Resident 20, who was on EBP due to bilateral lower extremity open wounds. Similarly, CNA 3 did not wear a gown while assisting Resident 7, who was on EBP due to an indwelling urinary catheter. These lapses in following EBP protocols were acknowledged by the staff involved and confirmed by the DSD/IP.
Improper Blood Pressure Measurement Procedure
Penalty
Summary
The facility failed to ensure that the services provided met professional standards of care when a Licensed Vocational Nurse (LVN) did not properly obtain the blood pressure of a resident during medication administration. The LVN placed the blood pressure cuff and the diaphragm of the stethoscope over the resident's long sleeve shirt instead of directly on the skin, as required by the facility's policy and procedure for measuring blood pressure. This action was observed during a medication administration observation, where the resident's blood pressure was recorded as 152/90 mm/Hg. Interviews with the LVN, the Director of Staff Development/Infection Preventionist (DSD/IP), and the Director of Nursing (DON) confirmed that the correct procedure for obtaining blood pressure involves placing the cuff and stethoscope diaphragm directly on the skin. The LVN acknowledged that placing the equipment over clothing could lead to inaccurate readings and difficulty in hearing the pulsation. The DSD/IP confirmed that licensed nurses are trained on the correct procedure during orientation, and the DON acknowledged the findings of the deficiency.
Failure to Provide ROM Exercises for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the range of motion (ROM) for Resident 8, who had limited mobility and ROM functions. Despite the facility's policy stating that residents with limited ROM should receive treatment to prevent further decline, Resident 8 did not receive physical therapy or ROM exercises since her admission. The resident expressed her desire for therapy to regain her ability to walk, but there was no evidence of physical therapy orders or RNA services in her medical records. The care plan for Resident 8 included daily ROM exercises, both active and passive, but there was no documentation to show these exercises were provided. Interviews with facility staff, including RNA 1, CNA 2, LVN 1, and the DON, confirmed that Resident 8 did not receive the necessary ROM exercises. RNA 1 stated that long-term residents receive RNA services after evaluation by the PT, but Resident 8 had not been evaluated. CNA 2 mentioned that CNAs help maintain ROM for residents who do not qualify for PT, but there was no documentation of such exercises for Resident 8. LVN 1 and the DON verified the lack of documentation and acknowledged that Resident 8 should have been receiving daily ROM exercises. This oversight had the potential to lead to a decline in Resident 8's physical abilities.
Failure to Complete Smoking Assessment for Resident
Penalty
Summary
The facility failed to complete a smoking assessment for a resident upon admission, as required by their Smoking Policy revised in July 2017. This policy mandates that residents who smoke must be assessed with a safe smoking assessment tool upon admission to determine if they are safe to smoke. Despite the resident being taken to the smoking area by staff and supervised while smoking, the necessary assessment was not documented in the resident's medical record. This oversight was confirmed during an interview with the LVN, who was unable to locate the assessment in the resident's records, and acknowledged by the DON. The resident, who was admitted to the facility on an unspecified date, was found to have the capacity to understand and make decisions according to their H&P examination dated May 8, 2024. However, the absence of a documented safe smoking assessment posed a potential risk for accidents or injuries. The facility had recently transitioned to a new EHR system, which may have contributed to the oversight, but this does not negate the requirement for the assessment to be completed and documented as per the facility's policy.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to physician's orders for oxygen therapy for two residents, leading to potential negative impacts on their medical conditions. For Resident 13, the oxygen concentrator was set at 5 liters per minute, contrary to the physician's order of 4 liters per minute as needed to maintain oxygen saturation levels above 90%. This discrepancy was confirmed by the Director of Staff Development/Infection Preventionist (DSD/IP) during an observation and interview, acknowledging that the staff should have followed the physician's order. Resident 17 was observed without the prescribed continuous oxygen therapy of 2 liters per minute via nasal cannula, as per the physician's order for dyspnea. The resident was seen without the nasal cannula on multiple occasions, and the Certified Nursing Assistant (CNA) confirmed that the resident removed it due to personal discomfort, although this refusal was not documented. The Licensed Vocational Nurse (LVN) verified the resident's oxygen saturation level was 82% on room air, which improved to 100% when oxygen was administered at the prescribed rate.
Deficiencies in Side Rail Use and Documentation
Penalty
Summary
The facility failed to ensure the safety and proper use of side rails for four residents, leading to potential accident hazards. For Resident 13, the Facility Verification of Informed Consent was incomplete, lacking a physician's signature and date, and there was no physician's order for the use of bilateral half side rails. Despite the resident's diagnosis of Alzheimer's disease, which allowed for decision-making capacity, these procedural oversights were confirmed by the DSD/IP during an observation and interview. Resident 20's care plan did not address the use of bilateral half side rails, despite a physician's order for their use to aid in bed mobility and repositioning. The resident had the capacity to understand and make decisions, yet the absence of a care plan meant that staff were not adequately informed on how to care for the resident regarding side rail use. This was verified by the DSD/IP during an interview. For Resident 12, the facility failed to complete a side rail assessment and did not provide the manufacturer's manual to ensure compatibility between the bed and side rails. The resident, diagnosed with advanced dementia and Parkinson's-type tremors, lacked decision-making capacity. Additionally, Resident 1's assessment did not document alternative, least restrictive measures or assess the risk of entrapment. The DSD/IP confirmed that no alternatives were tried, and no care plan or risk assessment was completed for the resident's side rail use.
Failure to Assess Bowel Status Before Administering Laxatives
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for Resident 8, as observed during a medication administration session. Licensed Vocational Nurse (LVN) 1 administered laxative medications, including polyethylene glycol and Senna, without assessing the resident's bowel status or reviewing the medical record for bowel elimination, as required by the physician's orders. The facility's policy and procedure for administering medications, revised in April 2019, mandates that medications be administered in accordance with prescriber orders, which was not adhered to in this instance. Resident 8, who was readmitted to the facility on an unspecified date, had a history and physical examination indicating the ability to communicate needs but an inability to make medical decisions. The physician's orders specified that the laxatives should be held in the case of loose stool, a directive that was not followed by LVN 1. During an interview, LVN 1 confirmed the failure to assess the resident's bowel status, attributing it to the resident's consistent request for laxatives and stool softeners. The Administrator and Director of Nursing (DON) were informed of these findings and acknowledged the deficiency.
Failure to Address Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's drug recommendations were addressed for two residents, leading to potential adverse consequences related to their medications. For Resident 17, the facility did not address the Pharmacy Consultant's recommendations regarding the duration of therapy for Preparation H and the suggestion to switch from Benadryl to a less sedating antihistamine. Despite the Director of Nursing (DON) stating that the process involved notifying the physician and documenting the actions taken, there was no evidence in the medical record that these recommendations were addressed until after the surveyor's inquiry. For Resident 1, the facility did not document any follow-up on the Pharmacy Consultant's recommendation to evaluate the need for a stop date for the PRN psychotropic medication lorazepam, as per CMS guidelines. Although the Director of Staff Development/Infection Preventionist (DSD/IP) claimed that the physician was contacted, there was no documented evidence to support this. Additionally, an LVN confirmed that Resident 1 had not shown signs of anxiety or required lorazepam administration during the day shift in the past two months, yet the recommendation remained unaddressed in the medical record.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 11.11%. Two licensed vocational nurses (LVNs) were involved in medication administration errors. LVN 1 did not follow the physician's order for Resident 8 by reconstituting polyethylene glycol medication with five ounces of water instead of the prescribed eight ounces. This discrepancy was confirmed during an interview with LVN 1, who admitted to using the incorrect amount of water due to the size of the plastic cup used. Similarly, LVN 2 made errors during medication administration for Resident 3. LVN 2 also reconstituted polyethylene glycol with five ounces of water instead of the required eight ounces. Additionally, LVN 2 failed to administer the prescribed vitamin B12 supplement to Resident 3, despite signing the medication administration record (MAR) as if it had been given. LVN 2 acknowledged the error, stating the vitamin B12 was not available in the medication cart. The Director of Nursing (DON) was informed and acknowledged these findings.
Deficiencies in Hospice Care Documentation and Coordination
Penalty
Summary
The facility failed to ensure that two residents receiving hospice services had the necessary documentation and care plans in place. For Resident 1, the hospice visit calendar was missing from the medical record, and there was no accurate documentation of hospice staff visits. Additionally, the care plan was not updated to reflect the hospice services being provided. Interviews with facility staff confirmed the absence of the hospice visit calendar and the lack of documentation for hospice aide visits as ordered. Resident 1's medical record also lacked an updated physician certification and hospice plan of care beyond November 2024, despite the resident being under hospice care. The facility's Director of Staff Development/Infection Preventionist (DSD/IP) acknowledged these deficiencies, noting that the care plan should have been updated to include visits from various hospice staff. The absence of these documents posed a risk of delayed communication and provision of hospice care. Similarly, for Resident 13, the hospice visit calendar was not available in the medical record, and there was no care plan addressing the hospice services provided. The DSD/IP confirmed that a care plan should have been in place to ensure facility staff were aware of the resident's hospice care plan. The lack of a calendar also meant that facility staff were not informed of the hospice staff's scheduled visits, which could impact the coordination of care for the resident.
Failure to Implement QAPI Action Plans for Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented action plans to monitor the effectiveness of those plans in achieving and sustaining improvement for a repeated deficient practice cited at F756. This deficiency was identified during a review of the facility's policies and procedures, which outlined the QAPI plan's process for identifying and correcting quality deficiencies. Key components of this process included tracking and measuring performance, establishing goals, identifying and prioritizing deficiencies, analyzing underlying causes, developing corrective actions, and monitoring the effectiveness of these actions. However, the facility did not adhere to these components, as evidenced by the failure to implement a monitoring system for the pharmacy consultant recommendations. During an interview with the Administrator and the Director of Nursing (DON), it was revealed that the DON did not assign the charge nurse to review and address the Drug Regimen Review (DRR) cited in the previous recertification survey. The DON admitted to placing the DRR in a binder but failed to assign it to a licensed nurse for follow-up and communication with the physician. This oversight was a direct violation of the facility's Plan of Correction (POC) from the last recertification survey, which required routine weekly audits of the pharmacy consultant recommendations to ensure completion on a monthly basis. The failure to implement these corrective actions had the potential to affect the quality of care for all residents in the facility.
Glucometer Quality Control Discrepancy
Penalty
Summary
The facility failed to maintain essential equipment, specifically a glucometer, in safe operating condition. During an inspection, it was found that the quality control records for February and March 2025 did not match the saved results on the glucometer with serial number 1040-4333929. The documented quality control results for several dates in February and March were not observed on the device's memory. For instance, the normal control result of 96 mg/dl and the high control result of 256 mg/dl documented on February 1, 2025, were missing from the glucometer's saved results. This discrepancy was verified by an LVN and acknowledged by the DON.
Inaccurate Bed Measurements Pose Entrapment Risk
Penalty
Summary
The facility failed to ensure accurate completion of entrapment assessments for four residents, which could potentially lead to serious harm. Observations and reviews revealed that the bed measurements, including bed frame lengths, mattress lengths, and mattress heights, were inaccurately recorded. This discrepancy was confirmed by the Maintenance Supervisor and acknowledged by the Administrator, who noted the importance of accurate measurements for resident safety. The facility's policy on the proper use of side rails requires assessments to determine the risk of entrapment, but these assessments were not accurately completed for the residents involved. Resident 13, who has Alzheimer's disease, was observed with elevated side rails, intended to aid in mobility and repositioning. Similarly, Resident 20 had a physician's order for side rails to assist with mobility, yet the bed measurements were inaccurate. Resident 12 and Resident 1 also had discrepancies in their bed measurements, specifically regarding mattress height. These inaccuracies in bed system assessments could lead to potential entrapment, posing a risk of serious injury or death to the residents.
Failure to Update POLST and Obtain Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's Physician Orders for Life-Sustaining Treatment (POLST) was updated and that a copy of the advance directive form was obtained. This deficiency was identified for one of the twelve sampled residents. The medical record review for the resident showed that the POLST, dated August 2, 2024, indicated no advance directive, despite an Advance Directive Acknowledgement form dated August 5, 2024, showing that the resident's family had executed an advance directive. During an interview and concurrent medical record review, both the Licensed Vocational Nurse (LVN) and the Social Services/Activities Director confirmed that the resident's family had executed an advance directive. However, the POLST was not updated to reflect this, and the facility did not follow up with the family to obtain a copy of the advance directive. The Social Services/Activities Director acknowledged these findings.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to the residents and their representatives, as well as to the LTC Ombudsman, for two residents. Resident 21 was transferred to an acute care hospital due to a possible G-tube infection or dislodgement, but there was no documented evidence that the resident or their representative received a written notification of the transfer and its reason. Additionally, the facility did not send a copy of the notice to the LTC Ombudsman. Interviews with the Office Manager and LVN 1 confirmed these findings, and they were unable to provide documentation of the required notifications. Similarly, for Resident 26, who was discharged to home, the facility failed to send a copy of the Notice of Transfer/Discharge to the LTC Ombudsman. The section for sending a copy to the Ombudsman was left blank on the notice. The Social Services/Activities Director confirmed that the notice was not sent and could not provide documentation to show that the Ombudsman was notified about the resident's discharge. These failures posed a risk of the residents and their representatives not being informed about the appeal process and the LTC Ombudsman not being aware of the circumstances of the transfers or discharges.
Failure to Complete and Transmit MDS for Discharge
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for discharge was completed and transmitted for one of the sampled residents, identified as Resident 12. This deficiency was identified during a medical record review initiated on March 5, 2025. Resident 12 had been readmitted to the facility after a stay in an acute care hospital from October 14 to October 18, 2024. However, the review of the transmitted MDS assessments revealed that the MDS reflecting Resident 12's discharge in October 2024 was not completed. This oversight was confirmed during an interview with the Administrator on March 4, 2025.
Inaccurate MDS Coding for RNA Services
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident regarding Restorative Nursing Program (RNA) services. Specifically, the MDS quarterly assessments for the resident, dated November 5, 2024, and February 5, 2025, had Section O for RNA left blank. This omission was discovered during a medical record review initiated on March 3, 2024. The resident had physician's orders for RNA services, including wearing a left knee orthosis and bilateral PRAFO, as well as active assist and passive range of motion exercises, which were not reflected in the MDS. Interviews with the MDS Coordinator and the Director of Staff Development/Infection Preventionist (DSD/IP) revealed that the MDS Coordinator did not have access to the electronic health record (EHR) to view the RNA program for the resident, leading to the inaccurate coding. The DSD/IP confirmed that the resident had been receiving RNA services since September 2024, and acknowledged the inaccuracy in the MDS. This failure posed a risk of the resident not receiving an individualized care plan tailored to their specific needs.
Failure to Revise Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to revise the care plan for a resident after the resident reported an abuse allegation against a Certified Nursing Assistant (CNA). The resident, who had a moderately impaired cognition with a BIMS score of 9, alleged that the CNA pushed her off a shower chair and put a hand around her throat. Despite this serious allegation, the care plan for the resident was not updated to reflect the incident or to include any new interventions to address the reported abuse. Interviews with the Licensed Vocational Nurse (LVN), Director of Nursing (DON), and Director of Staff Development (DSD) confirmed that no new or revised care plan was created following the abuse allegation. The facility's policy and procedure for comprehensive, person-centered care plans require that care plans include measurable objectives, describe services to maintain the resident's well-being, and incorporate identified problem areas and risk factors. The failure to update the care plan was acknowledged by the Administrator and DON during the interview.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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