Sunland Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Sunland, California.
- Location
- 8647 Fenwick Street., Sunland, California 91040
- CMS Provider Number
- 056031
- Inspections on file
- 63
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Sunland Post Acute during CMS and state inspections, most recent first.
A resident with severely impaired cognition, type 2 DM with neuropathy, and a history of a Stage 3 pressure ulcer experienced a documented decline in both skin condition and functional status. An MDS assessment early in the stay showed no pressure ulcers and a need for maximal assistance with several ADLs, while later skin assessments and weekly pressure injury records showed a persistent Stage 3 pressure ulcer to the buttock, and OT notes documented a change from minimal assist to total dependence for lower body dressing. Despite these changes not returning to baseline within two weeks, staff did not complete a Significant Change in Status Assessment (SCSA) MDS as required by the RAI guidelines.
Two residents’ clinical records were not accurately or consistently documented. For one resident, an LVN reviewed abnormal lab results and obtained a physician response of no new orders but failed to document the physician’s response. For another resident with a Stage 3 pressure ulcer to the buttock, the wound was documented on skin assessments and weekly pressure injury records, but the MDS and discharge skin assessment recorded no pressure ulcers and intact skin. The RN completing the discharge documentation reported being in a hurry and not verifying the existing pressure ulcer. Facility policy requires current, accurate, and detailed documentation consistent with good medical and professional practice.
A cognitively intact resident with multiple chronic conditions, including neuropathy, heart failure, and leukemia, reported that a Business Office Manager opened her Medi-Cal mail without permission and then brought the already-opened statement to her room. The staff member admitted opening the mail while acting as manager of the day, stating she assumed it was intended for the business office and did not verify the addressee. The facility’s Resident Rights policy states that residents have the right to privacy in sending and receiving mail unopened, which was not followed in this incident.
A resident with intact cognition and significant neurological deficits requested transfer to an ALF closer to a friend, but the SSD did not document the resident’s discharge needs, expressed goals, or the ongoing discharge planning efforts in the medical record. Despite working on insurance changes to facilitate ALF placement, the SSD acknowledged that no notes had been entered regarding the discharge planning process, contrary to facility policy requiring IDT involvement and timely documentation of community-return interest, referrals, feasibility determinations, and discharge plan details.
A resident with a history of intracerebral hemorrhage and left-sided hemiplegia/hemiparesis, who had intact cognition and required varying levels of staff assistance with ADLs, requested transfer to an ALF closer to a friend. The Social Services Director acknowledged being aware of this request and being responsible for discharge care plans, yet the resident’s comprehensive care plan did not include any discharge planning goals, interventions, or measurable timeframes. This omission was inconsistent with facility policies requiring a comprehensive, resident-centered care plan and an updated discharge plan focused on the resident’s discharge goals.
A resident with severe cognitive impairment and multiple medical conditions experienced an unwitnessed fall resulting in a forehead injury and severe pain. Staff initiated a 72-hour neuro check protocol, but the ADON later determined that the required 30-minute and subsequent interval assessments were not performed or documented at the correct times. After the resident was transferred to and then returned from an acute care hospital, the 72-hour neuro checks were not resumed and documented according to the facility’s specified timetable, contrary to facility policies on neurological checks and documentation accuracy.
A resident with severe cognitive impairment and a history of fracture had a PRN order for acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain rated 1–4/10. After an unwitnessed fall causing a forehead bump and severe pain rated 8/10, an LVN administered acetaminophen despite the order’s pain-scale parameters and did not contact the physician for alternative pain management. Documentation on the SBAR and MAR showed acetaminophen was given for pain documented as 7–8/10, contrary to the prescribed range and the facility’s pain management and medication administration policies.
The facility failed to reconcile and document controlled medications in five emergency kits and two medication carts, resulting in missing accountability logs and discrepancies in medication counts for a resident prescribed lacosamide for seizures. Nursing staff did not consistently sign off on controlled medication administration as required by policy, and required shift-change reconciliation of emergency kits was not performed.
Surveyors found that staff failed to document medication refrigerator temperatures twice daily as required, and did not remove expired budesonide inhalation solutions from a medication cart. These actions were not in accordance with facility policy or manufacturer guidelines, affecting two residents who required proper medication storage and administration.
A nurse left a medication cart computer unlocked and unattended, allowing potential access to residents' EHRs. Staff interviews confirmed that computers should be locked when unattended to protect resident privacy, in accordance with facility policy.
A resident's tray table was found dirty and cluttered during mealtime, while two residents near the smoking patio were repeatedly exposed to a loud alarm triggered by staff entering and exiting the gate. Staff and the DON confirmed that these conditions did not meet expectations for cleanliness and a calm, homelike environment.
Three residents did not have individualized care plans addressing their specific needs and risks. Two residents who smoked lacked care plans specifying the required level of supervision during smoking, and another resident prescribed Klonopin did not have a care plan addressing the medication's black box warning. Facility staff confirmed that these care plans were not resident-centered and did not provide clear guidance for staff interventions.
The facility did not ensure a safe environment for several residents by failing to accurately assess fall risk for a resident with a recent fall, leaving disinfectant wipes within reach of a cognitively impaired resident, and allowing two residents to possess lighters and cigarettes despite facility policy. In addition, smoking risk assessments for these residents were unclear, leading to confusion among staff about required supervision and safety interventions.
Three residents experienced medication errors when nursing staff administered medications at incorrect times or provided the wrong formulation, resulting in a medication error rate of 12%. Staff acknowledged administering medications outside the required time window and not following physician orders, despite facility policies mandating accurate and timely medication administration.
A resident with severe cognitive impairment and no decision-making capacity was placed on a wander guard, a physical restraint, without obtaining informed consent from the responsible party. The facility initially documented the resident as self-responsible due to lack of family information, but after learning of family involvement, did not secure the required written consent, contrary to facility policy.
The facility did not maintain a copy of an advance directive in the medical record for a resident with Alzheimer's disease and hypertension, and failed to provide written information about advance directives to another resident with sepsis and pyelonephritis. Staff interviews confirmed that required documentation and information were not provided or available as per facility policy.
A resident with severe cognitive impairment and a history of elopement risk was placed on one-to-one monitoring after removing a wander guard, but the responsible party was not notified of this significant change in care. Facility staff and documentation confirmed the lack of communication, despite policy requiring notification and documentation of such changes.
A resident with severe cognitive impairment and diabetes was not given a completed SNF ABN form prior to the end of Medicare Part A coverage. The responsible party was notified and signed the form 19 days after coverage ended, rather than at least 72 hours in advance, and the required options regarding care and financial responsibility were not selected. The facility lacked a policy for beneficiary notices and did not follow CMS guidelines for timely notification.
A resident with severe cognitive impairment and a history of stroke was placed on a wander guard, classified as a physical restraint by facility policy, without consistent documentation or evidence of wandering behavior. Despite physician orders and hourly monitoring, staff interviews and records confirmed the resident refused the device and did not attempt to leave the facility. The facility failed to provide required documentation supporting the use of the restraint, resulting in a deficiency.
A resident with severe cognitive impairment and no decision-making capacity was admitted with conditions including hemiplegia and aphasia. The facility failed to adequately involve the resident's responsible party in IDT care plan meetings, making only a single phone call attempt without further follow-up, despite policy requiring efforts to ensure family or representative participation.
A resident with diabetes consistently received insulin injections in the same abdominal site without rotation, contrary to professional standards and facility policy. Record review and staff interview confirmed repeated administration in the left lower quadrant, despite the facility's procedures requiring site rotation to prevent injury.
A resident with dysphagia and severe cognitive impairment did not receive a physician-ordered large portion breakfast due to a breakdown in communication between nursing and kitchen staff. The order, recommended by the RD and approved by the physician, was not relayed to the kitchen, resulting in the resident receiving regular portions instead of the prescribed large portion for several weeks.
A resident with respiratory failure and other chronic conditions did not receive oxygen therapy at the flow rate ordered by the physician. The oxygen was set below the prescribed range, and staff confirmed that the physician's order was not followed, contrary to facility policy requiring medications to be administered as prescribed.
Surveyors found that the facility did not maintain the required concentration of quaternary ammonium sanitizing solution for cleaning kitchen surfaces, with repeated tests showing levels below 100 ppm instead of the required 200 ppm. Additionally, a resident with hypertension and diabetes was observed with leftover food from outside left unrefrigerated at the bedside for over 24 hours, contrary to facility policy. These deficiencies were confirmed through staff interviews, direct observation, and policy review.
A resident with multiple health conditions and impaired cognition was not offered the required pneumococcal vaccine dose, and the necessary consent form was missing from their record. Staff interviews confirmed the oversight, which was not in accordance with the facility's policy to evaluate and offer the vaccine to all residents.
A resident with impaired cognition and significant medical conditions did not receive a COVID-19 booster vaccine after their representative provided consent. Despite documentation of consent and facility policy requiring vaccination, no physician order was placed and the vaccine was not administered, as confirmed by both the IPN and DON.
A resident with multiple medical conditions was observed self-administering medications at bedside without an interdisciplinary team (IDT) assessment or physician order, contrary to facility policy. Staff confirmed that the resident had been self-administering since admission, and the required evaluation and documentation for self-administration were not completed.
A resident with severe cognitive impairment and multiple medical conditions exhibited a long-standing behavior of spitting, which was managed informally by staff but not addressed in a formal care plan. The DON was unaware of the behavior, and the required comprehensive care plan did not include interventions or measurable objectives for this issue, contrary to facility policy.
A resident with multiple medical conditions, including metabolic encephalopathy and diabetes, was administered lorazepam as ordered for anxiety, but the administration was documented only on the MAR and not on the Individual Count Sheet Record as required by facility policy. The DON confirmed the discrepancy, which involved a lack of immediate documentation on the accountability record for a controlled substance.
Staff failed to properly account for and secure a discontinued bottle of lorazepam prescribed to a resident with multiple medical conditions, resulting in the medication going unaccounted for. The prescription number on the medication record did not match the bottle found in the medication room, and the DON confirmed the missing bottle was not received for safekeeping or destruction as required by facility policy.
A resident with end stage renal disease and diabetes was repeatedly served meals containing carbohydrates despite documented preferences and dietary orders to avoid them. The facility did not update the resident's dietary profile during the required quarterly review, and staff acknowledged that the resident's food preferences were not honored, in violation of facility policy.
Surveyors found that clear storage cups of sugar-free gelatin, prepared for residents with diabetes, were not labeled or dated according to facility policy. Both the Dietary Aide and Director of Dietary Services confirmed the labeling requirement, and the deficiency had the potential to affect a large number of residents receiving food from the kitchen.
A resident with hemiplegia, a history of falls, and moderate cognitive impairment was found to have a non-functioning call light, which was only operable after being plugged in by a nurse supervisor. Facility policy required that all residents be shown how to use the call light and that staff ensure it is within reach and operable, but this was not followed, resulting in the deficiency.
A resident's transfer or discharge was not managed in a way that met their needs and preferences, and the facility did not ensure the resident was adequately prepared for a safe transition.
A resident with cognitive impairment and multiple medical conditions was transferred to a hospital for a mental health evaluation without being provided the required bed hold notice. Facility staff confirmed that neither the resident nor their representative received written information about the bed hold policy prior to the transfer, despite facility policy requiring such notification.
A resident with severe cognitive and physical impairments was physically assaulted by a roommate with similar cognitive deficits, resulting in multiple facial and hand injuries that required hospital treatment. The incident occurred after the resident called for nursing assistance, prompting the roommate's aggressive response. Staff discovered the situation after hearing distress from the room, and the facility's abuse prevention policy was not effectively followed, leading to actual harm.
A resident with severe cognitive impairment and a history of psychosis experienced multiple episodes of yelling after discontinuation of Seroquel. Nursing staff documented the behavioral changes but did not notify the physician as required by facility policy, resulting in a failure to communicate a significant change in condition.
A resident with severe cognitive impairment and physical disabilities was struck by a roommate, resulting in facial injuries and hospital transfer. The facility failed to report the alleged abuse to the SSA within the required two-hour timeframe, submitting the report seven minutes late, contrary to its own policy and federal requirements.
A resident with dementia and psychosis had Seroquel discontinued, after which multiple episodes of yelling were documented. Despite facility policy and staff awareness of the need for ongoing behavioral monitoring and weekly progress notes, documentation was missing for two weeks, and there was no consistent assessment of the resident's psychosocial status following the medication change.
A resident with anxiety, dementia, and depression was given trazodone PRN for insomnia without a specified duration, contrary to facility policy requiring a 14-day limit and reevaluation. The DON confirmed the oversight, as the medication was administered multiple times without adhering to the policy.
The facility failed to maintain a safe environment by not addressing roof and ceiling damage, leading to water leaks in resident rooms and the kitchen. Several residents, including those with dementia and multiple sclerosis, were affected, with some refusing to move despite feeling unsafe. Observations revealed significant ceiling damage, and the facility's maintenance policies were not followed.
A facility failed to revise a care plan to include specific interventions for the use of a mechanical lift for a resident with cerebral infarction, hemiplegia, and hemiparesis. The care plan did not specify the need for two staff members to assist with transfers, as required by facility policy. Interviews with the MDSC and DON confirmed the oversight, indicating the care plan was not updated to meet the resident's specific needs, potentially affecting care provision.
A CNA in a LTC facility failed to provide the required two-person assistance when using a mechanical lift to transfer a resident with cerebral infarction and hemiplegia. The CNA operated the lift alone due to unavailability of staff, contrary to facility policy. The resident required total assistance for transfers, and the facility's policy mandated two staff members for safety.
A resident with severe cognitive impairment and a care plan requiring the call light to be within reach was found with the call light hanging off an overhead lamp, out of reach. A nurse confirmed the necessity of the call light for timely assistance, as per facility policy.
A resident with schizophrenia and anxiety was allegedly locked in a family room by the DON, witnessed by a CNA. The SSA was informed but did not report the incident immediately to the ADM, delaying the required report to the State Survey Agency. The facility's policy requires immediate reporting of abuse, which was not followed.
A facility failed to implement infection control practices by not labeling a resident's urinal bottles, which were found unlabeled during an observation. The resident, with COPD and hypertension, required assistance with hygiene. The facility's policies emphasized labeling personal items to prevent infection spread, which was not followed.
A resident with cerebral infarction, hypertension, and hypothyroidism was not informed of a TSH test result, which was conducted without a physician's order. The test result was significantly outside the normal range, and neither the resident nor their responsible party was notified, violating the resident's rights to be informed about their care and treatment.
A resident with cerebral infarction, hypertension, and hypothyroidism underwent a TSH test without a physician order, resulting in a significantly elevated TSH level. The facility's policy requires physician orders for diagnostic tests, which was not followed, posing a risk to the resident's care plan.
A resident experienced untreated pain due to a lack of monitoring and care for an IV line by RN 3. Despite complaints of pain and visible blood around the IV site, RN 3 continued administering antibiotics without checking the line's patency. The resident, with a complex medical history, required substantial assistance and had an IV line inserted for antibiotic treatment. The IV site was later found infiltrated and removed by RN 4. Interviews revealed RN 3's inaction, and the facility lacked a policy on IV administration.
A facility failed to set a low air loss mattress (LALM) correctly for a resident, risking skin breakdown, and did not measure another resident's heel ulcers for six weeks. The first resident's LALM was set for a higher weight than needed, without a physician's order. The second resident's heel ulcers were not measured, contrary to facility policy, hindering assessment of healing.
Failure to Complete SCSA MDS After Resident’s Decline in Skin and Functional Status
Penalty
Summary
Facility staff failed to complete a Significant Change in Status Assessment (SCSA) MDS for a resident who experienced a notable decline in skin condition and functional status that did not return to baseline within two weeks. The resident was originally admitted on 1/20/2026 and later readmitted with diagnoses including thoracic intervertebral disc degeneration, a Stage 3 pressure ulcer to the left buttock, and type 2 DM with diabetic neuropathy. An MDS dated 1/23/2026 documented severely impaired cognition, no pressure ulcers/injuries, and a need for maximal assistance with toileting hygiene, tub/shower transfers, lower body dressing, sit-to-lying, and lying-to-sitting on the side of the bed. Subsequent skin and body assessments and weekly pressure injury records dated in March and April 2026 showed the presence and continued existence of a Stage 3 pressure ulcer to the left buttock, which differed from the earlier MDS documentation of no pressure ulcer. In addition to the skin changes, an OT Therapy Progress Report covering services from 4/1/2026 through 4/7/2026 documented a decline in the resident’s functional status for lower body dressing. The report indicated that the prior level of function for lower body dressing was minimal assist, while the baseline, previous, and current status all reflected total dependence with attempts to initiate. According to the RAI Manual, Chapter 2, an SCSA must be completed when the IDT determines that a resident has a significant change in condition from baseline that is not expected to return to baseline within two weeks. Despite the documented decline in both skin condition and functional status compared to the most recent comprehensive assessment, the facility did not complete the required SCSA MDS for this resident.
Failure to Maintain Accurate and Consistent Clinical Documentation
Penalty
Summary
The deficiency involves failures to maintain accurate and complete clinical records for two residents in accordance with accepted medical and professional standards. For one resident with diagnoses including lumbar radiculopathy, COPD, and intervertebral disc degeneration, a CBC with differential dated 4/15/2026 had a handwritten note indicating it was seen and reviewed on 4/16/2026 and that orders were awaited. The LVN later stated that the physician had responded the same day with no new orders but acknowledged that he did not document the physician’s response because it was busy that day, despite recognizing that he should have documented it. For another resident with diagnoses including thoracic intervertebral disc degeneration, a Stage 3 pressure ulcer to the left buttock, and type 2 DM with diabetic neuropathy, multiple records contained inconsistent documentation of the pressure ulcer. The admission record and subsequent skin and body assessment, as well as weekly pressure injury records, documented the presence and continuation of a Stage 3 pressure ulcer to the left buttock. However, the MDS indicated no pressure ulcers, and the discharge skin and body assessment documented intact skin with no pressure ulcers. The RN who completed the discharge form stated the resident was transferred via 911 and that she was in a hurry and did not double check the presence of the Stage 3 pressure ulcer. The DON stated that nurses are expected to accurately document the care they provide and that incomplete or inaccurate documentation can negatively impact the resident’s plan of care. The facility’s documentation policy requires that clinical records be current, detailed, and consistent with good medical and professional practice, with entries that are accurate, timely, objective, specific, concise, legible, clear, and descriptive.
Resident Mail Opened in Violation of Privacy Rights
Penalty
Summary
The facility failed to ensure a resident’s right to receive mail unopened, as required by its Resident Rights policy. The resident, who had diagnoses including idiopathic progressive neuropathy, heart failure, and leukemia, was cognitively intact per a recent MDS and required varying levels of assistance with ADLs but was independent with eating and oral hygiene. The resident reported that the Business Office Manager (BOM) entered her room and showed her a Medi-Cal statement that had already been opened, which the resident stated was done without her permission and in violation of her rights. In an interview, the BOM acknowledged that on the date in question, while working as manager of the day, she opened the resident’s mail without verifying the intended recipient, assuming it was for the business office. The Administrator confirmed that the BOM should not have opened the resident’s mail and that staff should not open mail not addressed to them or their department. Review of the facility’s Resident Rights policy indicated that residents have the right to privacy in sending and receiving mail unopened, which was not followed in this instance.
Failure to Document Resident Discharge Planning and Needs
Penalty
Summary
The deficiency involves the facility’s failure to implement its discharge planning process policy by not documenting a resident’s discharge needs and discharge plan. The resident was admitted with significant neurological conditions, including nontraumatic intracerebral hemorrhage, hemiplegia, and hemiparesis following cerebral infarction affecting the left dominant side. An MDS assessment showed the resident had intact cognition, required varying levels of staff assistance with oral hygiene, personal hygiene, and toileting, and was independent with eating. The resident had expressed a desire to transfer to an assisted living facility closer to a friend. The Social Services Director acknowledged awareness of the resident’s request to transfer to an assisted living facility and stated that placement would be difficult due to the resident’s insurance coverage and income. The Social Services Director reported assisting the resident with changing insurance to qualify for assisted living placement but admitted that no notes or documentation of the discharge planning process, including efforts made, had been entered into the resident’s medical record. The Social Services Director attributed the lack of documentation to overseeing many residents and stated it was important to document the discharge planning process so staff involved in the resident’s care would be aware of the discharge plan. This lack of documentation was inconsistent with the facility’s written discharge planning policy, which requires IDT involvement, documentation of the resident’s interest in community return, referrals, determinations of feasibility, and timely documentation of the evaluation of discharge needs and plans.
Failure to Develop Person-Centered Discharge Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive, person-centered care plan addressing a resident’s discharge plan. The resident was admitted with nontraumatic intracerebral hemorrhage and resulting left-sided hemiplegia/hemiparesis following cerebral infarction, and an MDS assessment showed intact cognition, with varying levels of assistance needed for ADLs such as oral hygiene, personal hygiene, and toileting, and independence with eating. Despite these identified needs and the resident’s expressed desire to transfer to an assisted living facility closer to a friend, the resident’s care plan did not include any discharge planning goals, interventions, timetables, or measurable actions related to this requested transition. During interview and concurrent record review, the Social Services Director acknowledged awareness that the resident had requested transfer to an ALF and confirmed that there was no care plan addressing the resident’s discharge plan. The Social Services Director further stated that they were responsible for developing residents’ discharge care plans and that this resident should have had a discharge care plan so that staff involved in the resident’s care would be aware of the resident’s needs and goals. Review of the facility’s Comprehensive Care Planning and Discharge Planning Process policies showed that the facility’s procedures require a comprehensive resident-centered care plan with measurable objectives and timeframes, and that the discharge planning process must focus on discharge goals and updating the comprehensive care plan and discharge plan as appropriate, which had not been done for this resident.
Failure to Accurately Complete Required 72-Hour Neuro Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to provide resident-centered care and services by not accurately completing a required 72-hour neurological assessment following an unwitnessed fall experienced by Resident 1. Resident 1 had been admitted with diagnoses including atrial fibrillation, muscle weakness, and a non-displaced fracture of the medial malleolus of the right tibia, and had severely impaired cognition per the most recent MDS. On the date of the incident, an SBAR Communication Form documented that Resident 1 had an unwitnessed fall resulting in a bump to the right forehead and severe forehead pain rated 8 out of 10. A 72-hour neuro check list was initiated at 8:30 p.m. in accordance with facility practice for unwitnessed falls; however, during review, the Assistant Director of Nursing (ADON) identified that the required assessment intervals were not accurately completed. Specifically, the every-30-minute neurological checks were not performed at the correct times, as they should have occurred at 9:15 p.m. and 9:45 p.m., but were instead documented at 9:00 p.m. and 9:30 p.m. Further review of the clinical record showed that Resident 1 was transferred to an acute care hospital later that evening and returned to the facility the following morning at 5:15 a.m. The ADON stated that, based on the documented return time, the 72-hour neurological checks should have resumed upon arrival and followed specific four-hour and subsequent interval times over the next several days, but the documentation did not reflect that these intervals were followed as required. The facility’s policies titled "Neurological Checks" and "Documentation Principles" required that neurological checks be conducted for 72 hours after a fall with head impact, using the appropriate form and timetable, and that the clinical record be current, accurate, timely, and consistent with good medical and professional practice. The inaccurate timing and incomplete documentation of the neuro checks for Resident 1, as identified by the ADON during record review, constituted the deficiency.
Failure to Follow PRN Pain Medication Parameters After Resident Fall
Penalty
Summary
The facility failed to administer pain medication in accordance with a physician’s order based on a documented pain scale for one resident. The resident was admitted with diagnoses including atrial fibrillation, muscle weakness, and a non-displaced fracture of the right medial malleolus. An MDS assessment indicated the resident had severely impaired cognition and required staff assistance with oral, toileting, and personal hygiene. The physician’s order, dated 6/29/2025, specified acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain rated 1–4 on a 0–10 pain scale. The resident’s care plan for chronic pain/discomfort included an intervention to provide consistent and sufficient pain medication tailored to the individual. On a date in December, the resident experienced an unwitnessed fall resulting in a bump to the right forehead and severe forehead pain rated 8/10 on a pain scale. An SBAR form documented the fall, the severe forehead pain, and that an ice pack and Tylenol were provided, without specifying the dose. The MAR for that month showed that acetaminophen was administered at 8:45 p.m. for forehead pain with a documented pain level of 7/10. The LVN later stated the resident had reported pain at 8/10, that acetaminophen was given for this level of pain, and that the MAR entry of 7/10 was incorrect. During interview and record review, the ADON confirmed that acetaminophen 325 mg, two tablets, was administered for a reported pain level of 7/10, acknowledged that the order limited use to pain levels 1–4/10, and stated the physician should have been contacted for a stronger pain medication appropriate to the higher pain level. Facility policies on pain management and medication administration required pain assessment with documented ratings and administration of medications as prescribed by the physician.
Failure to Reconcile and Document Controlled Medications in Emergency Kits and Medication Carts
Penalty
Summary
The facility failed to reconcile and account for five medication emergency kits (eKITs) containing controlled medications (CMs) for the months of November and December 2025. This deficiency was observed in three medication rooms and one medication cart, where accountability logs for the reconciliation of CM inventory at every shift change were missing. Additionally, there were discrepancies in the count of CMs, specifically lacosamide, in two medication carts for a resident with a seizure disorder. The counts in the medication bubble packs did not match the documentation on the accountability logs, and there was no record of subsequent administrations to explain the missing doses. During observations and interviews, it was revealed that licensed nurses administered doses of lacosamide but failed to sign off on the Antibiotic or Controlled Drug Record accountability logs as required by facility policy. Both nurses acknowledged that they did not follow the policy of signing each CM dose on the accountability log after preparing and administering the medication. The Assistant Director of Nursing and the Director of Nursing confirmed that the eKITs containing CMs were not reconciled at every shift change, and that the required accountability and reconciliation logs were not maintained for the specified period. The resident involved had a diagnosis of epilepsy and was prescribed lacosamide 200 mg twice daily for seizure disorder. The facility's policies required that all CMs, including those in emergency kits, be counted and documented at every shift change by two licensed nurses, and that administration of CMs be immediately recorded on the accountability record and the Medication Administration Record (MAR). These procedures were not followed, resulting in unaccounted doses and missing documentation for both individual resident medications and emergency kits containing controlled substances.
Failure to Monitor Vaccine Refrigerator Temperatures and Remove Expired Medications
Penalty
Summary
Surveyors identified that the facility failed to properly monitor and document the temperature of a medication refrigerator containing vaccines in one of the medication rooms. Specifically, the temperature log for the refrigerator in Medication Room Station 2 showed that temperatures were only recorded once daily over a specified period, despite facility policy and manufacturer guidelines requiring twice-daily monitoring. The Assistant Director of Nursing (ADON) confirmed that several licensed nurses did not monitor or document the refrigerator temperature as required, making it unclear whether the vaccines were stored within the recommended temperature range. Additionally, the facility failed to remove and discard expired budesonide inhalation solutions from a medication cart. An open foil pouch containing four remaining budesonide inhalation solutions for a resident with COPD was found stored at room temperature beyond the two-week period recommended by the manufacturer after opening. Both the LVN and the DON acknowledged that the expired medication should have been removed and that several licensed nurses failed to do so, contrary to facility policy and manufacturer instructions. The facility's policies require that medications and biologicals be stored according to manufacturer recommendations, with expired or deteriorated medications immediately removed from stock. The surveyors' review of the facility's policies and the manufacturer's guidelines confirmed that these requirements were not met in the instances observed, resulting in the presence of expired medications and inadequate monitoring of vaccine storage conditions.
Unattended Unlocked Computer on Med Cart Exposes Resident Records
Penalty
Summary
Licensed Vocational Nurse 3 (LVN 3) left the computer on the medication cart in Station 3 unlocked and unattended, providing potential access to residents' electronic health records (EHR). This was observed during a survey, where the computer screen was found open and accessible, allowing anyone to potentially view confidential resident information. Both Registered Nurse 5 (RN 5) and LVN 3 acknowledged that the computer should have been locked when unattended to prevent unauthorized access to residents' records. The Director of Nurses (DON) confirmed that facility policy requires licensed nurses to lock computers when leaving the medication cart to maintain residents' privacy. The facility's policy and procedure on Resident Rights, last reviewed on 5/14/2025, states that residents are to be assured confidential treatment of their financial and medical records. The failure to lock the computer, even when not displaying a specific resident's record, was recognized as a breach of this policy and had the potential to compromise the privacy of all residents in the facility.
Failure to Maintain Cleanliness and Minimize Excessive Noise in Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for three of five sampled residents. For one resident with severely impaired cognition and multiple medical diagnoses, the tray table used during mealtimes was observed to be dirty and cluttered with unnecessary items such as an opened disinfectant wipes container, gloves, masks, disposable undergarments, and plastic bags. This was confirmed by a registered nurse, who acknowledged that the tray table should be clean and uncluttered during meals, and by the Director of Nursing, who stated that residents' rooms should always be clean and clutter-free to promote a homelike environment. Additionally, two other residents, both cognitively intact and with various medical conditions, were affected by frequent activation of an alarm located near their rooms. The alarm, connected to the smoking patio gate, was triggered repeatedly as staff entered and exited through the gate to access laundry, maintenance storage, and the parking area. During a two-hour observation period, the alarm sounded 34 times. Staff interviews revealed that the alarm often activated because the time allowed to enter the deactivation code was insufficient. Both residents reported being disturbed by the frequent alarm noise, with one stating that the sound bothered him when his door was open and the other noting that he had become accustomed to the noise over time. The Director of Nursing confirmed that excessive noise from the alarm could disrupt the calm, homelike environment expected for residents, especially those with rooms near the smoking patio door. Facility policy requires maintaining a safe, clean, and comfortable environment for all residents.
Failure to Develop and Implement Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans that addressed the specific needs and risks of three residents. For two residents with a history of smoking, the care plans did not specify the required level of supervision during smoking activities, despite facility policy and interdisciplinary team notes indicating that such details should be included. The care plans contained general interventions such as education on smoking risks and safe disposal of cigarette butts, but lacked individualized instructions regarding supervision or the use of safety equipment like smoking aprons. Both the RN and DON confirmed that the care plans were not resident-centered and did not provide staff with clear guidance on the necessary interventions to ensure safety during smoking. For another resident prescribed Klonopin, an antianxiety medication with a black box warning, the care plan did not address the specific risks associated with the medication. Although the resident had severe cognitive impairment and was dependent on staff for most activities of daily living, the care plan failed to mention the black box warning for Klonopin, which includes risks of abuse, addiction, dependence, and withdrawal reactions. Both the RN and DON acknowledged that the care plan should have included these details to enable appropriate monitoring and staff awareness of the medication's dangers. The facility's policies and procedures require that comprehensive, resident-centered care plans be developed for each resident, including measurable objectives and timeframes based on the comprehensive assessment. The deficiencies identified in the report were due to the omission of individualized interventions and failure to address specific risks in the care plans, as observed during interviews and record reviews with facility staff.
Failure to Prevent Accident Hazards and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for four of eight sampled residents. For one resident with a history of falls and multiple diagnoses including acute respiratory failure, depression, schizophrenia, and generalized muscle weakness, the fall risk assessment was not accurately completed. Despite documentation of a recent fall and reported pain, the fall risk evaluation did not reflect this incident, leading to a lack of appropriate identification and intervention for fall risk as outlined in the facility's policies. Another resident with severely impaired cognition and chronic medical conditions was found to have an open container of disinfectant wipes left unattended and within reach on their tray table. Staff acknowledged that it was unsafe for this resident to have access to chemicals, and facility policy prohibits residents from having flammable or unsafe chemicals at the bedside. The presence of the disinfectant wipes posed a risk of accidental poisoning, especially given the resident's cognitive impairment. Additionally, two residents were found in possession of lighters and cigarettes, contrary to the facility's smoking policy, which requires all smoking materials to be stored in locked areas and prohibits residents from carrying such items. Staff interviews and documentation revealed that the smoking risk assessments for these residents were unclear and did not specify whether they required supervision while smoking. This lack of clarity led to confusion among staff regarding the necessary safety interventions and resulted in residents possessing smoking materials unsupervised, increasing the risk of fire hazards.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, resulting in a 12% error rate during the observed period. Three medication errors were identified out of 25 opportunities, affecting three residents. Specifically, one resident received aspirin at a time different from the physician's order, another received a multivitamin with minerals instead of the prescribed multivitamin without minerals, and a third resident received carvedilol at a time inconsistent with the physician's order. Observations and interviews revealed that the errors were due to deviations from prescribed medication administration times and incorrect medication selection. Nursing staff acknowledged administering medications outside the facility's 60-minute window for scheduled doses and providing a formulation of a supplement that did not match the physician's order. The staff involved recognized these incidents as medication errors during interviews and explained the discrepancies between the orders and the actual administration. Record reviews confirmed the physician orders for each resident, including specific instructions regarding timing and formulation of medications. Facility policies required medications to be administered as prescribed, within a one-hour window of the scheduled time, and for staff to verify the correct medication, dosage, time, and route before administration. The documented errors occurred despite these policies, as staff failed to adhere to the established guidelines and physician orders.
Failure to Obtain Informed Consent for Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that informed consent was obtained from a resident's responsible party prior to the use of a physical restraint, specifically a wander guard device, for a resident with severe cognitive impairment and no decision-making capacity. The resident was admitted with diagnoses including hemiplegia following a stroke and aphasia, and was assessed as severely impaired in cognition and unable to make decisions. Despite this, the initial informed consent form for the wander guard indicated the resident was self-responsible and unable to sign, as the facility was unaware of any family at the time. After the facility became aware that the resident had family, there was no documented attempt to obtain written consent from the responsible party, even though the facility's policy required informed consent from the resident or legal representative for the use of physical restraints. The interdisciplinary team attempted to contact the family for a care plan meeting, but the family did not respond or attend. The facility's policies also required that residents or their representatives receive all information regarding risks, benefits, and alternatives to proposed care, including the use of restraints, in advance.
Failure to Maintain and Provide Advance Directive Documentation
Penalty
Summary
The facility failed to implement its policy and procedure regarding advance directives for two residents. For one resident with Alzheimer's disease and hypertension, the facility did not maintain a copy of the resident's advance directive in either the electronic medical record or the physical chart, despite documentation indicating that the resident had executed such a directive. During an interview, a registered nurse confirmed the absence of the advance directive in the records and acknowledged the importance of having this document accessible to honor the resident's healthcare wishes, especially in emergencies. The facility's policy requires that a copy of the advance directive be provided for the resident's clinical record if one exists. For another resident with diagnoses including sepsis, pyelonephritis, and lack of coordination, the facility did not provide written information about the right to prepare an advance directive upon admission, nor could staff locate the required acknowledgement form in the resident's records. Interviews with the Social Service Director and the Director of Nursing confirmed that it is standard procedure to check for an advance directive or provide information on how to formulate one at admission. The facility's policy states that residents must be given written information about their rights under state law to prepare an advance directive prior to or upon admission.
Failure to Notify Responsible Party of One-to-One Monitoring Assignment
Penalty
Summary
The facility failed to inform a resident's responsible party about the initiation of one-to-one monitoring for a resident who was unable to make their own medical decisions. The resident in question was admitted with diagnoses including hemiplegia following a stroke, aphasia, and was assessed as severely cognitively impaired and unable to make decisions. The resident was identified as being at risk for elopement, had previously worn a wander guard, and had removed the device, refusing its reapplication. As a result, staff began one-to-one monitoring to ensure the resident's safety. Despite this significant change in the resident's care, there was no documentation or evidence that the responsible party was notified about the implementation of one-to-one monitoring. Interviews with facility staff, including the Director of Staff Development, a Registered Nurse, and the Director of Nursing, confirmed that the responsible party was not informed of this intervention. The responsible party also stated during an interview that neither she nor the former responsible party had been notified about the one-to-one sitter assignment, learning about the removal of the wander guard only through another family member. Facility policy required that family members or responsible parties be notified of any change in condition, with documentation of the notification in the nurses' notes. The care plan and physician's orders did not reflect the one-to-one sitter intervention, and there was no record of communication to the responsible party regarding this change. This omission constituted a failure to uphold the resident's right to have their representative informed of significant changes in treatment and services.
Failure to Provide Timely SNF ABN Notification for Medicare Coverage Termination
Penalty
Summary
The facility failed to provide a completed Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) in writing to a resident or their responsible party prior to the end of Medicare Part A coverage, as required. Specifically, the SNF ABN form for a resident with severe cognitive impairment and diabetes was not completed to indicate the resident's or representative's choice among the three required options regarding continued care and financial responsibility. The form was signed by the responsible party 19 days after the last covered day, rather than at least 72 hours before coverage ended, as confirmed by both the Accounts Receivables Supervisor and the Director of Nurses during interviews. The facility did not have a policy for beneficiary notices and relied on CMS guidelines, which require timely notification to allow beneficiaries to make informed decisions about their care and financial obligations. The failure to provide the SNF ABN in a timely manner meant the resident or their representative was not properly informed in advance of the end of Medicare coverage and the potential for out-of-pocket costs, nor were they given the opportunity to appeal the decision or determine the course of care before coverage ended.
Failure to Document and Justify Use of Physical Restraint (Wander Guard)
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of physical restraints, specifically in the application and documentation of a wander guard device for a resident. The resident in question was admitted with diagnoses including hemiplegia following a stroke, aphasia, and severe cognitive impairment. Despite the resident's cognitive status, multiple assessments and monitoring sheets indicated that the resident did not exhibit wandering behavior during their stay, and there were no documented episodes of elopement or attempts to leave the facility. Physician orders were in place for the use of a wander guard, and the resident was monitored hourly, but documentation supporting the ongoing need for the device was inconsistent. The resident's care plan and risk assessments fluctuated, at times indicating risk for elopement and at other times not, without clear rationale documented for these changes. Staff interviews confirmed that the resident refused to wear the wander guard and that there were no observed incidents of wandering or exit-seeking behavior. The facility's policy classified the wander guard as a physical restraint, requiring specific documentation and justification for its use, which was not consistently present in the resident's record. The lack of proper documentation and justification for the use of the wander guard, as required by facility policy, resulted in a deficiency. Staff and leadership acknowledged that the absence of supporting documentation for the restraint could violate the resident's rights and potentially result in psychological harm. The facility's own policies also required that episodes of wandering or exit-seeking behavior be documented in the medical record, along with the interventions used and their effectiveness, which was not done in this case.
Failure to Involve Resident's Representative in Care Plan Meetings
Penalty
Summary
The facility failed to involve a resident's representative or responsible party during the Interdisciplinary Team (IDT) care plan meetings, both quarterly and annually, for one resident who was reviewed under the accidents care area. The resident in question was admitted with diagnoses including hemiplegia following a stroke, aphasia, and was documented as severely cognitively impaired and unable to make decisions. The Minimum Data Set (MDS) and History and Physical (H&P) confirmed the resident's severe cognitive impairment and lack of decision-making capacity. Despite this, the facility's records indicated that the resident did not have any emergency contacts listed at admission, and subsequent care plan conference summaries showed that the responsible party was contacted only once by phone and did not return the call or attend the meeting. Further review and interviews with facility staff, including a Registered Nurse and the Director of Nurses (DON), confirmed that only a single attempt was made to contact the responsible party, with no documented follow-up efforts. The facility's policy and procedure on care planning emphasized the importance of involving the resident's family or legal representative in the development and revision of the care plan and making every effort to schedule meetings at convenient times. However, the lack of adequate follow-up to ensure participation resulted in the resident's representative not being involved in the care planning process.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that insulin injection sites were rotated for a resident with type 2 diabetes mellitus, as required by professional standards of practice and the facility's own policies. Record review showed that the resident, who had intact cognitive skills and required assistance with activities of daily living, consistently received insulin injections in the same location—the left lower quadrant of the abdomen—over multiple documented administrations. The Medication Administration Record (MAR) detailed repeated injections at this same site across several dates, without evidence of site rotation. During an interview, a registered nurse confirmed that insulin injection sites should be rotated to prevent injury and acknowledged that repeated injections at the same site can cause pain. Review of the facility's policies on insulin and medication administration further confirmed the requirement for site rotation and adherence to physician orders. The failure to rotate injection sites was identified through both interview and record review, and it was noted that this practice did not align with professional standards or facility policy.
Failure to Communicate and Implement Physician's Dietary Order
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and services to maintain acceptable parameters of nutritional status for a resident with multiple diagnoses, including dysphagia, unspecified psychosis, and major depressive disorder. The resident was totally dependent on staff for self-care and had severely impaired cognitive skills. A physician's order was issued to provide a large portion at breakfast, following a recommendation from the registered dietitian to meet the resident's nutritional needs. Despite the physician's order, the kitchen staff did not receive notification of the dietary change. The kitchen supervisor confirmed that the resident's meal tray card did not reflect the large portion order and stated that no communication or ticket had been received from the nursing department regarding the new order. The registered dietitian and the director of nursing both explained that the process requires nursing staff to communicate dietary orders to the kitchen for implementation, but this step was missed in this case. The registered nurse confirmed that the order for a large portion breakfast was not carried out until several weeks after it was written. Facility policy requires that residents receive care and services consistent with their comprehensive assessment and care plan, including dietary needs. The failure to communicate and implement the physician's order resulted in the resident not receiving the prescribed large portion breakfast for an extended period.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards of practice for a resident with a history of respiratory failure, diabetes mellitus, and obesity. The resident was admitted and later readmitted to the facility, and their Minimum Data Set indicated they had intact cognition but required moderate to total assistance with activities of daily living. The resident was documented as receiving oxygen therapy. During an observation and record review, it was found that the resident's oxygen was set at 1.5 liters per minute (LPM), while the physician's order specified continuous oxygen at 2-4 LPM every shift. The Director of Staff Development confirmed that the oxygen flow rate did not match the physician's order and acknowledged the risk of desaturation. The Director of Nursing also stated that licensed nurses are expected to follow physician orders to ensure the prescribed oxygen flow rate is administered. Facility policy requires medications, including oxygen, to be administered as prescribed.
Failure to Maintain Proper Sanitizing Solution Concentration and Safe Handling of Outside Food
Penalty
Summary
The facility failed to maintain the required concentration of quaternary ammonium sanitizing solution used for cleaning kitchen surfaces. During an observation, a staff member tested the sanitizing solution and found it to be below 100 ppm, which is less than the required 200 ppm as per facility policy. The staff member attempted to replace the solution, but the new batch also tested below 100 ppm. The kitchen supervisor confirmed the low concentration and acknowledged that the solution would not be effective for disinfecting food preparation surfaces. The facility's policy requires the solution to be tested and recorded at least twice daily, and to be replaced if the concentration falls below 200 ppm. Additionally, the facility did not ensure that food items brought from outside for a resident were properly refrigerated or discarded within the required timeframe. A resident with hypertension and type 2 diabetes was observed with leftover food from the previous day on their overbed table. The resident confirmed that the food had been brought by a family member the day before and had not been refrigerated. The Director of Nursing stated that food from outside must be consumed immediately or refrigerated, and that food left at the bedside from the previous day is not safe for consumption. Review of facility policies confirmed that food items brought in for residents are not to be reheated or stored, and must be consumed or discarded promptly. The failure to follow these procedures was observed both in the kitchen's sanitizing practices and in the handling of outside food for a resident, as documented through staff interviews, direct observation, and record review.
Failure to Offer and Document Pneumococcal Vaccine per Facility Policy
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccine was offered to one of seven sampled residents, as required by its own policy. The resident in question was originally admitted in 2019 and re-admitted in 2025 with diagnoses including acute respiratory failure with hypoxia, sepsis, and diabetes mellitus. Review of the resident's Minimum Data Set indicated moderately impaired cognition and dependence on staff for activities of daily living. During a review of the resident's immunization record, it was found that the last pneumococcal vaccine dose was administered in 2023, but the required consent form for the vaccine was missing, and there was no documentation that the vaccine had been offered as per policy. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that the resident was due for a second dose of the pneumococcal vaccine and that the facility was responsible for verifying and offering the vaccine to all residents as needed. The facility's policy stated that all residents should be evaluated for pneumococcal vaccination status upon admission and offered the vaccine unless medically contraindicated or already immunized. The failure to offer and document the vaccine for this resident constituted a deficiency in following established procedures.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to administer a COVID-19 booster vaccine to a resident after the resident's representative provided verbal consent for vaccination. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, and cerebral infarction, had moderately impaired cognition and was dependent on staff for activities of daily living. Review of the resident's records showed that the last COVID-19 vaccine dose was administered in 2021, and although consent for a booster was obtained in November 2025, there was no physician order or documentation indicating that the vaccine was ordered or given. Interviews with the Infection Preventionist Nurse (IPN) and the Director of Nursing (DON) confirmed that the resident had not received the COVID-19 booster despite the consent being documented. The facility's policy required offering COVID-19 vaccinations to all residents per CDC and FDA guidelines unless medically contraindicated, already immunized, or refused. The failure to administer the vaccine after obtaining consent constituted a deficiency in following the facility's vaccination protocol.
Failure to Assess Resident for Self-Administration of Medications by IDT
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) was involved in assessing and determining the appropriateness of self-administration of medications for a resident. The resident, who had diagnoses including type 2 diabetes, lumbar spine disc degeneration, hypertension, and a history of lung cancer, was admitted with intact cognition and some need for assistance with activities of daily living. Despite these conditions, the resident was observed organizing and self-administering medications at bedside without an IDT assessment or documented approval for self-administration. The resident reported having self-administered medications since admission and had not participated in an IDT meeting regarding this practice. Facility staff, including an LVN and the DON, confirmed that the resident had been self-administering medications without the required IDT assessment or physician order. The facility's policy requires that the IDT assess each resident's ability to self-administer medications and determine the safety and appropriateness of this practice, with documentation in the care plan. This assessment had not been completed for the resident, and the required procedures for storage, documentation, and ongoing quarterly reassessment were not followed.
Failure to Develop and Implement Care Plan for Spitting Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's behavior of spitting. The resident, who was admitted with diagnoses including diabetes mellitus, hyperlipidemia, dementia, and dysphagia, was found to have severely impaired cognition and was dependent on staff for most activities of daily living. Despite a long history of spitting, as reported by a Certified Nursing Attendant (CNA), there was no care plan in place to address this behavior. The CNA described providing the resident with a small trash can and reminders to spit into it, but these interventions were not documented in a formal care plan. During interviews and record reviews, the Director of Nursing (DON) confirmed being unaware of the resident's spitting episodes and acknowledged the absence of a care plan for this behavior. The facility's policy requires a comprehensive, resident-centered care plan to be developed for each resident, including measurable objectives and timeframes based on identified needs. However, the care plan for this resident did not address the spitting behavior, resulting in a failure to deliver necessary care and services as outlined in the facility's own procedures.
Failure to Reconcile Controlled Substance Administration Records
Penalty
Summary
The facility failed to ensure that the Medication Administration Record (MAR) and the Individual Count Sheet Record for controlled substances coincided as required by facility policy for one resident. Specifically, a resident with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus with hyperglycemia, and who was receiving palliative care, was readmitted and had a physician's order for lorazepam oral concentrate to be administered as needed for anxiety. On a specified date, the MAR indicated that lorazepam was administered to the resident, but there was no corresponding documentation on the Individual Count Sheet Record to confirm this administration. During an interview and record review, the DON confirmed that the MAR showed lorazepam was given, but the Individual Count Sheet Record did not reflect this, which was inconsistent with facility policy. The policy required that when a controlled medication is administered, the licensed nurse must immediately document the administration on both the accountability record and the MAR, including the date, time, amount, and nurse's signature or initials. The failure to document on both records as required was observed and acknowledged by the DON.
Failure to Account for and Secure Discontinued Controlled Medication
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles, specifically regarding the handling of a discontinued bottle of lorazepam for one resident. The resident, who had multiple diagnoses including metabolic encephalopathy, type 2 diabetes mellitus with hyperglycemia, and was receiving palliative care, had a physician's order for lorazepam oral concentrate to be administered as needed for anxiety over a 14-day period. After the medication was discontinued, the bottle with the original prescription number could not be located during a review of medication records and physical inventory. During interviews and record reviews, it was found that the prescription number on the resident's Individual Count Sheet Record did not match the bottle present in the locked medication room. The Director of Nursing (DON) confirmed that the discontinued lorazepam bottle was not received for safekeeping and was not documented as destroyed according to facility policy. The DON also stated that the medication destruction log did not show that the missing bottle had been destroyed, and the bottle was ultimately unaccounted for. Facility policy requires that discontinued controlled substances be brought to the DON, locked for safekeeping, and destroyed in the presence of the DON and a pharmacist, with proper documentation. The failure of licensed nurses to follow these procedures resulted in the loss of accountability for the controlled medication, as the bottle of lorazepam was not properly secured or disposed of after discontinuation.
Failure to Honor Resident Food Preferences and Update Dietary Profile
Penalty
Summary
The facility failed to provide meals that accommodated a resident's food preferences and did not implement its own food preference policy by neglecting to update the resident's dietary profile during the required quarterly review. The resident, who had diagnoses including end stage renal disease, type 2 diabetes mellitus with hyperglycemia, mild protein-calorie malnutrition, and was dependent on renal dialysis, was admitted with specific dietary needs, including a renal/no added salt/consistent carbohydrate diet and a stated dislike for carbohydrates. Despite these documented preferences and dietary orders, the resident was repeatedly served meals containing carbohydrates such as rice, pasta, bread, and cake. The resident reported to staff that these items were consistently provided despite his expressed dislike and concern for their impact on his blood sugar. Observations and interviews confirmed that the kitchen staff did not honor the resident's preferences, and the Director of Dietary Services acknowledged that the resident's dietary profile had not been updated as required during the last quarterly review. The facility's policy required food preferences to be updated at least quarterly or as the resident's needs changed, but this was not done for the resident in question. As a result, the resident's food preferences were not honored, and the facility did not follow its own procedures for updating and documenting dietary preferences.
Failure to Label and Date Prepared Gelatin in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to follow proper food handling practices by not labeling and dating clear storage cups of gelatin according to the facility's policy. During an inspection of the kitchen refrigerator, open food items, specifically clear storage cups containing gelatin, were found without labels or dates. The Dietary Aide confirmed that 11 of these cups were not labeled, and identified them as sugar-free gelatin intended for residents with diabetes. The Director of Dietary Services also confirmed that these items should have been labeled with both the food description and the date of preparation or opening, as per facility policy. A review of the facility's policy and procedure on labeling and dating of foods indicated that all food items in storage, including prepared foods, must be covered, labeled, and dated. The failure to label and date the gelatin cups was a direct violation of this policy. This deficiency had the potential to affect 109 out of 116 residents who receive food from the facility's kitchen.
Non-Functioning Call Light in Resident Room
Penalty
Summary
A deficiency was identified when a resident with a history of hemiplegia following a stroke, a history of falls, and moderate cognitive impairment was found to have a non-functioning call light in their room. During an observation, the call light was tested and found not to be operating. The Registered Nurse Supervisor confirmed the call light was not working and noted it needed to be plugged in to function. After plugging it in, the call light operated properly. The resident's records indicated they had the capacity to understand and make decisions, and the facility's policy required that all residents be shown how to use the call light and demonstrate its use upon admission. The Director of Nursing confirmed that all residents should have a functioning call light to alert staff of their needs. The facility's policy also stated that staff should ensure the call light is within easy reach and operable for residents when they are in bed, a wheelchair, or a chair in the room. The failure to ensure the call light was functioning as required led to the deficiency.
Failure to Ensure Resident-Centered and Safe Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed, resulting in a deficiency related to resident-centered care and safe transition planning.
Failure to Provide Bed Hold Notice Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide a required bed hold notice to a resident and/or the resident's responsible party prior to the resident's transfer to a general acute care hospital. The resident, who had a history of cognitive impairment, dependence on staff for activities of daily living, and multiple medical and psychiatric diagnoses, was transferred under a physician's order for a 72-hour mental health evaluation. Upon review of the resident's records, there was no documented evidence that the resident or their representative was informed about the facility's bed hold policy at the time of transfer. Interviews with facility staff, including a registered nurse and the director of nursing, confirmed that no bed hold notice was provided and that there was uncertainty regarding the need for a physician's order for a bed hold. The facility's own policy required written notification to the resident or their representative about the bed hold policy prior to transfer, but this was not followed in this instance.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and significant physical limitations was subjected to physical abuse by his roommate. The incident involved the roommate striking the resident multiple times in the face with a fist, resulting in multiple injuries including hematomas and lacerations to the face, nose, lip, chin, and hand. The injuries were severe enough to require transfer to an acute care hospital for evaluation and suturing. The resident was observed with a bloody face and was later readmitted to the facility with visible wounds closed by stitches and ongoing hematomas and bruising. The abused resident had a history of cerebral infarction with hemiplegia and hemiparesis, as well as dementia, and was dependent on staff for most activities of daily living. At the time of the incident, the resident was calling for nursing assistance, which reportedly triggered the roommate's aggressive behavior. The roommate, who also had severely impaired cognition and a history of alcohol dependence, became agitated and physically assaulted the resident. Staff became aware of the incident after hearing screaming and entered the room to find the injured resident and the roommate unable to explain the event. The facility's policy on abuse prevention and resident safety was not effectively implemented, as evidenced by the occurrence of the assault and the resulting harm to the resident. The Director of Nursing confirmed that the incident constituted physical abuse and resulted in actual harm. The report documents the sequence of events, the residents' medical and cognitive conditions, and the immediate observations and assessments following the incident.
Failure to Notify Physician of Behavioral Change After Psychotropic Discontinuation
Penalty
Summary
The facility failed to notify a resident's physician regarding an increase in episodes of yelling after the discontinuation of Seroquel, an antipsychotic medication. The resident in question had a history of dementia, psychosis, hemiplegia, and hemiparesis following a cerebral infarction, and was admitted with severe cognitive impairment and high dependence on staff for daily activities. The physician had discontinued Seroquel, which was previously prescribed for psychotic disorder manifested by yelling. Following the discontinuation of Seroquel, the resident experienced multiple episodes of yelling, as documented in the Medication Administration Record (MAR) over several days. Despite these documented behavioral changes, there was no evidence that the physician was notified of the increased episodes. Interviews with nursing staff confirmed that the episodes were recorded, but the physician was not informed for a psychiatric re-evaluation. A review of the facility's policy indicated that all changes in a resident's condition, including marked changes in mental behavior, should be documented and communicated to the physician and responsible party. However, documentation and interviews confirmed that the required notification and documentation did not occur in this case, resulting in a failure to follow established procedures for change of condition.
Failure to Timely Report Alleged Physical Abuse to State Survey Agency
Penalty
Summary
The facility failed to follow its policy and procedures for timely reporting of a reasonable suspicion of a crime, specifically regarding an allegation of physical abuse. An incident occurred in which one resident, who had a history of cerebral infarction with hemiplegia, hemiparesis, and dementia, was struck in the face by a roommate, resulting in facial cuts and a bleeding nose. The resident was noted to have severely impaired cognition and was dependent on staff for most activities of daily living. The incident was documented in the resident's records, and the physician was notified, resulting in the resident being transferred to a hospital for further evaluation and treatment. The facility's internal documentation indicated that the incident occurred in the late afternoon, with the nurse providing first aid and notifying the DON approximately 20 minutes after the event. The DON received the initial call at 5:45 p.m., and the facility's policy required that such allegations involving abuse be reported to the State Survey Agency (SSA) within two hours. However, the actual report to the SSA was sent at 7:52 p.m., which was seven minutes past the required two-hour window. This delay in reporting the alleged abuse resulted in a late notification to the SSA, which in turn delayed an onsite inspection to ensure the safety of other residents. The facility's policy, last reviewed in February 2025, clearly stated the requirement for immediate reporting, but the facility did not meet this standard in this instance.
Failure to Monitor Behavioral Health After Psychotropic Medication Discontinuation
Penalty
Summary
The facility failed to adequately monitor and provide ongoing assessment of a resident's behavioral health needs following the discontinuation of Seroquel, an antipsychotic medication. The resident, who had diagnoses including dementia, psychosis, and hemiplegia/hemiparesis after a cerebral infarction, was admitted with significant cognitive impairment and required extensive assistance with daily activities. After the physician discontinued Seroquel, the resident experienced multiple episodes of yelling, as documented in the Medication Administration Record over several days. However, the required weekly progress notes by licensed nurses were missing for two consecutive weeks during this period, and there was no evidence of consistent monitoring or documentation of the resident's emotional or psychosocial status after the medication change. Interviews with facility staff, including the MDS Coordinator, DON, and an LVN, confirmed that staff were aware of the need to monitor behavioral changes after discontinuing psychotropic medications and to notify the physician if behavioral issues increased. Despite this, the documentation was incomplete, and the facility's own policy required weekly progress notes to reflect the effectiveness of psychotropic medication changes and any side effects or interventions. The lack of ongoing assessment and documentation had the potential to negatively affect the resident's psychosocial well-being.
Failure to Limit PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not providing a duration for a PRN order of trazodone, a medication used to treat depression. The resident, who was admitted with diagnoses including anxiety disorder, dementia, and depression, had a physician order for trazodone to be administered as needed for insomnia. However, the order did not specify a duration, which is a requirement for PRN psychotropic medications to ensure they are limited to 14 days and then reevaluated by a physician. The resident's Medication Administration Record indicated that trazodone was administered multiple times in February without a specified duration, contrary to the facility's policy. During an interview, the Director of Nursing confirmed that the resident was receiving trazodone as needed and acknowledged the oversight in not limiting the PRN order to 14 days. The facility's policy requires that PRN psychotropic medications be limited to a specific duration and used only for clearly documented circumstances, which was not adhered to in this case.
Facility Fails to Maintain Safe Environment Due to Roof and Ceiling Damage
Penalty
Summary
The facility failed to maintain a safe and comfortable environment by not ensuring that the roof was free from cracks, holes, and other damage, which allowed rainwater to penetrate and drip into the space between the roof and ceiling. This resulted in water leaking into multiple areas of the facility, affecting several residents, staff, and visitors. On a rainy day, water leaks were observed in the rooms of several residents, including those with dementia, cerebrovascular disease, multiple sclerosis, and Alzheimer's Disease. The leaks led to room changes for some residents, although not all agreed to move, and buckets were placed to collect the dripping water. In one instance, a resident with dementia and their family member were moved to another room due to water leaking from the ceiling, but they returned to the original room once the leaking stopped. Another resident with multiple sclerosis refused to move despite feeling unsafe, opting to switch beds within the same room. Observations revealed cracks, discoloration, and missing chunks in the ceiling, indicating significant damage. The maintenance supervisor noted several holes near ceiling-mounted ventilation, but was unsure of their purpose. Additionally, the facility failed to maintain the ceiling structure in a shared resident room and the kitchen, where old, repatched areas with cracks and holes were observed. The maintenance supervisor and dietary aide noted that the kitchen ceiling had been repatched years ago, but the cracks and holes had not been addressed. The facility's policies on maintaining a sanitary and homelike environment and conducting regular maintenance inspections were not adhered to, contributing to the unsafe conditions.
Failure to Revise Care Plan for Mechanical Lift Use
Penalty
Summary
The facility failed to revise a care plan to include resident-centered interventions for the use of a mechanical lift for a resident who was admitted with diagnoses including cerebral infarction, hemiplegia, hemiparesis, and seizures. The resident's Minimum Data Set (MDS) indicated that they required total assistance from staff for various activities of daily living, including transfers. Despite this, the care plan did not specify the need for at least two staff members to assist with the mechanical lift, as required by the facility's policy. During interviews and record reviews, both the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) acknowledged that the care plan interventions were not marked to indicate the need for two staff members to assist with the mechanical lift. This oversight meant that the care plan was not revised to meet the resident's specific needs for transferring, which is a requirement for person-centered care plans. The facility's policy on mechanical lifts also mandates that two staff members should perform transfers to ensure safety. The facility's policy on comprehensive person-centered care plans emphasizes the need for measurable objectives and timetables to meet residents' needs. However, the failure to update the care plan with specific interventions for the mechanical lift use indicates a lapse in adhering to this policy. This deficiency had the potential to affect the provision of care for the resident, as the care plan was not individualized to address their specific transfer needs.
Failure to Provide Two-Person Assistance with Mechanical Lift
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) provided the required two-person assistance when using a mechanical lift to transfer a resident from the bed to a wheelchair. This deficiency was observed during a survey where CNA 1 was seen operating the mechanical lift alone, despite the facility's policy requiring two staff members for such transfers. The CNA admitted to transferring the resident alone because no other staff was available at the time. The resident involved in this incident had significant medical conditions, including cerebral infarction, hemiplegia, hemiparesis, and seizures, which necessitated total assistance for transfers. The resident's cognitive skills for daily decision-making were intact, but they required full support for personal hygiene, dressing, and transfers. The CNA acknowledged receiving instructions that the mechanical lift should be used with two-person assistance, especially given the resident's condition. The Director of Staff Development confirmed that the mechanical lift should always be operated by two staff members for safety reasons. The facility's policy, last reviewed in February 2024, clearly stated that the mechanical lift should be used by two staff members to ensure maximum safety. The failure to adhere to this policy posed a potential risk of discomfort and injury to the resident during the transfer.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 2, who was admitted with diagnoses including dysphagia and dementia. The resident's Minimum Data Set indicated severe cognitive impairment, and the care plan specifically required the call light to be within reach to prevent falls or physical injury. However, during an observation, the call light was found hanging off the overhead lamp, out of the resident's reach. A Registered Nurse confirmed that the call light should be accessible to the resident to allow them to signal for assistance, such as needing to use the toilet or requiring a change. The nurse acknowledged that the resident could suffer from skin breakdown if left soiled due to the inability to call for help. The facility's policy on call light usage, last reviewed earlier in the year, emphasized the importance of positioning the call light within the resident's reach to meet their needs promptly.
Failure to Timely Report Alleged Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident abuse to the State Survey Agency (SSA) within the required timeframe. The incident involved a resident with schizophrenia and anxiety, who was reportedly locked in a family room by the Director of Nursing (DON) after the resident was yelling. This incident was witnessed by a Certified Nursing Assistant (CNA). The Social Services Assistant (SSA) was informed of the incident by the CNA but did not report it immediately to the Administrator (ADM) as required by the facility's policy. The SSA believed the incident constituted abuse and should be reported right away but did not act because the ADM was busy and the SSA was not a direct witness to the event. The facility's policy mandates that any alleged abuse must be reported to the Department of Public Health within two hours. However, the SSA delayed notifying the ADM, which in turn delayed the reporting to the appropriate authorities. The ADM confirmed that the SSA and the unnamed CNA should have reported the incident immediately to ensure timely reporting to the Department of Public Health. The facility's policy clearly outlines the responsibility of mandated reporters to report any suspected abuse immediately, but this protocol was not followed in this case.
Failure to Label Urinal Bottles for Infection Control
Penalty
Summary
The facility failed to implement proper infection control practices by not labeling a resident's urinal bottles with the resident's name and room number. This deficiency was identified during an observation and interview with a Licensed Vocational Nurse (LVN), who confirmed the presence of two unlabeled urinal bottles belonging to a resident. One urinal bottle was found hanging on the right upper side of the resident's bed rail, while the other was on top of the resident's drawer. The LVN acknowledged that the facility staff should have labeled the urinal bottles to prevent the potential spread of infection and cross-contamination among staff and other residents. The resident involved in this deficiency had been admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD) and hypertension. The resident's Minimum Data Set (MDS) indicated that their cognition was intact, and they required moderate assistance with personal hygiene and were dependent on staff for toileting hygiene and bathing. The facility's policy on Resident Dignity/Resident Rights and Infection Control Guidelines emphasized the importance of labeling personal items to promote good infection control practices, which was not adhered to in this instance.
Failure to Inform Resident of Laboratory Results
Penalty
Summary
The facility failed to protect the rights of a resident by not ensuring that the resident and their responsible party were informed of a laboratory result. The resident, who was admitted with diagnoses including cerebral infarction, hypertension, and hypothyroidism, had intact cognition and was dependent on staff for various personal care activities. A Thyroid Stimulating Hormone (TSH) test was conducted on the resident without a physician's order, and the result, which was significantly outside the normal range, was not communicated to the resident or their responsible party. During an interview and record review, a registered nurse acknowledged that there was no physician order for the TSH test conducted, which should have been obtained prior to the test. The nurse also stated that the resident and their responsible party should have been informed of the test results as it is their right to be informed about the resident's care and treatment. The facility's policy on resident rights, which guarantees the right to be informed and participate in care planning, was not adhered to in this instance.
Failure to Obtain Physician Order for TSH Test
Penalty
Summary
The facility failed to obtain a physician order for a Thyroid Stimulating Hormone (TSH) test for a resident, identified as Resident 2, which was conducted on 8/7/2024. Resident 2 was admitted to the facility with diagnoses including cerebral infarction, hypertension, and hypothyroidism. The Minimum Data Set (MDS) indicated that Resident 2 had intact cognition and was dependent on staff for various personal care activities. Despite the absence of a physician order, the TSH test was performed, and the results showed a significantly elevated TSH level of 48.12 ulU/ml, compared to the normal reference range of 0.45 to 5.33 ulU/ml. During an interview and record review, Registered Nurse 2 confirmed that there was no physician order for the TSH test conducted on 8/7/2024. The facility's policy, titled 'Lab and Diagnostic Test Results-Clinical Protocol,' mandates that a physician must identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The failure to obtain a physician order before conducting the TSH test was acknowledged by RN 2, who stated that this oversight could affect the resident's plan of care and posed an increased risk for injury and harm to Resident 2.
Failure to Monitor and Address IV Site Pain
Penalty
Summary
Facility staff, specifically RN 3, failed to monitor and provide appropriate care for a peripheral intravenous (IV) line for a resident, identified as Resident 65. On 10/6/2024, Resident 65 complained of pain at the IV site on the left forearm, but RN 3 did not check the patency of the IV line or address the resident's complaint of pain. Despite the visible presence of blood around the IV tubing, RN 3 continued to administer the antibiotic Zosyn through the IV line without verifying its placement or checking for infiltration. Resident 65, who was admitted to the facility on 9/4/2024, had a medical history that included chronic obstructive pulmonary disease, atrial fibrillation, transient ischemic attack, and cerebral infarction. The resident required substantial assistance with daily activities and had an IV line inserted on 10/3/2024 for the administration of antibiotics to treat a wound infection. The IV line was later found to be infiltrated, causing pain and requiring removal on 10/7/2024 by RN 4. Interviews with Resident 65, their wife, and facility staff revealed that RN 3 did not take appropriate action when informed of the pain and visible issues with the IV site. The Director of Nursing confirmed that licensed nurses are expected to address any reported pain immediately. Additionally, the Medical Records Assistant indicated that there was no existing policy regarding IV medication administration and peripheral IVs, which may have contributed to the oversight.
Failure to Properly Set LALM and Measure Heel Ulcers
Penalty
Summary
The facility failed to ensure the proper setting of a low air loss mattress (LALM) for a resident, which could potentially increase the risk of skin breakdown. The resident, who was admitted with diagnoses including hypertension and osteoarthritis, was observed using a LALM set for a weight range of 320-400 pounds, despite weighing only 150 pounds. There was no physician's order for the use of the LALM, and the Director of Nursing (DON) acknowledged that an incorrect setting could lead to skin breakdown and infection. Additionally, the facility did not measure a resident's deep tissue injury (DTI) pressure ulcers on the heels for approximately six weeks. The resident, who had diagnoses including diabetes mellitus and Alzheimer's disease, had an order to cleanse and dress the heel wounds daily, but the facility failed to document the length, width, or depth of the wounds. The DON and a registered nurse confirmed the importance of documenting wound measurements to assess healing and adjust treatment plans accordingly. The facility's policy required weekly documentation of pressure ulcer characteristics, which was not followed in this case.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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