Sunray Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3210 W Pico Blvd, Los Angeles, California 90019
- CMS Provider Number
- 055870
- Inspections on file
- 97
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 22 (2 serious)
Citation history
Health deficiencies cited at Sunray Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including diverticulitis, muscle weakness, dysphagia, depression, and colostomy status, who was cognitively able to make decisions and required moderate to maximum assistance with ADLs, reported that a CNA providing night-shift care handled them roughly, threw towels onto their chest and colostomy site, and made threatening gestures with closed fists while warning the resident not to speak up. The facility suspended the CNA during an investigation but then allowed the CNA to return to work and provide direct care before receiving the required one-on-one in-service on abuse prevention and resident rights. The QA nurse and DSD confirmed that this abuse-related in-service was not completed until after the CNA had already resumed resident care, contrary to facility policy requiring such training prior to direct-care duties.
A resident with depression and chronic anxiety, who had intact cognition and an order for psychology consult and treatment as needed, reported that a CNA interacted with her in a threatening and aggressive manner, after which she experienced increased nocturnal anxiety, fear of falling asleep, and later stated she did not feel safe. Despite these documented emotional and behavioral changes, no behavioral or change-of-condition assessment was completed, no psychologist notes were present, and the care plan was not revised to address the new behavioral health symptoms. Facility staff, including social services and the MDS coordinator, confirmed that required behavioral assessments were not done, and the DON was unaware of the resident’s expressed lack of safety, contrary to facility policies on behavioral assessment, trauma-informed care, and comprehensive person-centered care planning.
A resident with severe cognitive impairment, dysphagia, and a full-code status was given a cookie by a visitor despite being on a pureed diet. Shortly afterward, the resident was found pale, unresponsive, not moving, and with food in the mouth. A CNA, an RNA, and an LVN responded but did not assess responsiveness, did not check for a pulse or breathing, and did not initiate CPR as required by facility policy and CPR guidelines. Instead, they focused on performing the Heimlich maneuver and moving the resident between the bed and a chair. CPR was only started after an RT arrived, found no pulse, and directed staff to return the resident to bed and begin resuscitation, resulting in a delay in basic life support for a full-code resident.
A resident with dementia, severe dysphagia, and a pureed gratification diet was care planned as at risk for aspiration but had no specific nursing interventions for dysphagia or diet management. The facility had a policy requiring visitors to inform nursing staff when bringing food and prohibiting sharing food with other residents, but staff did not educate visitors, did not document checks of outside food, and posted no signage about these requirements. A visitor who routinely brought food for another resident was never counseled about restrictions and, during a visit, gave a regular-texture chocolate chip cookie to the cognitively impaired resident on a pureed diet without consulting staff. Staff later found the resident unresponsive with cookie pieces in the mouth, attempted the Heimlich maneuver and CPR, and the resident was pronounced dead by paramedics, demonstrating a failure to prevent unsafe food from entering the resident environment and to provide adequate supervision for a high-aspiration-risk resident.
Surveyors found that the facility failed to develop individualized, person-centered care plans for dysphagia for four residents with documented swallowing disorders, cognitive impairment, and specialized diet or enteral feeding orders. Although each resident had diagnoses such as dysphagia, dementia, aphasia, or prior pneumonitis and required pureed or fortified diets or GT feedings, their care plan reports either lacked dysphagia care plans entirely or listed aspiration risk without any nursing interventions. The DON, an LVN, and the QAN all confirmed that facility policy requires each diagnosis to have a specific care plan with interventions such as diet orders, aspiration precautions, monitoring for coughing and shortness of breath, swallow evaluations by speech therapy, and education, and acknowledged that these dysphagia care plans were not initiated on admission. Staff stated that without such care plans, nurses would not know the specific treatment and interventions needed, creating a potential increased risk for aspiration and pneumonia.
The facility did not complete required competency evaluations and skills checklists for two CNAs, as mandated by its policies. The DSD confirmed missing documentation for both CNAs, and the DON acknowledged that without these evaluations, the facility could not assess staff knowledge or training needs.
A resident with severe cognitive impairment and total dependence on staff was found in an environment with a strong urine odor and a dirty, wet fall mat near the bed. The CNA acknowledged the odor and unclean conditions, noting that the resident's incontinence brief had not been changed due to being busy with other residents. The facility's policy for a clean and homelike environment was not upheld.
A resident with severe cognitive impairment and multiple medical diagnoses did not receive the ordered amount of enteral nutrition due to a feeding pump being turned off, resulting in only 200 ml being infused over 12 hours instead of the prescribed 960 ml. The discrepancy was confirmed by the DON, and the facility's policy requiring adequate nutritional support was not followed.
The facility failed to ensure timely and accurate medication administration, including late administration of blood pressure medication without physician notification, incomplete documentation of controlled substances, and lack of proper reassessment after PRN medication use. Additionally, two residents received insulin injections in the same sites without proper rotation, contrary to care plans and facility policy.
Staff did not adhere to the RCS diet guidelines by serving garlic bread to residents on a controlled-carbohydrate diet, despite clear instructions in the facility's food portioning and serving guide. Both the dietary aide and supervisory staff confirmed that garlic bread should not have been provided to these residents, as it was not part of the prescribed RCS meal plan.
Dietary staff failed to properly clean and sanitize cups, trays, and dishes, with food residue and tape remaining on items after dishwashing. Clean dishware was stored to air dry while still visibly soiled, and food particles were present on counters where clean items were placed. Staff interviews confirmed that dishes were not adequately scraped or rinsed before washing, resulting in improper cleaning and storage of kitchenware.
Three staff members, including an RN, LVN, and CNA, were found to have started employment without completed background checks, contrary to facility policy. This was discovered during a review following a resident's report of rough handling during care, which led to an abuse investigation. The facility's own policies required background checks before employment, but these were either delayed or missing for the staff involved.
Two residents with significant mobility impairments and pressure injuries did not have their call lights within reach, despite care plans and facility policy requiring accessibility. Staff observations confirmed that the call lights were either placed out of reach or left dangling off the bed, preventing the residents from calling for assistance when needed.
A resident with moderate cognitive impairment and acute kidney failure was discharged from Medicare Part A skilled services without being provided the required Notice of Medicare Non-Coverage (NOMNC). Facility staff and records confirmed the NOMNC was not issued, despite policy requiring advance notification before benefits end.
A resident with multiple advanced pressure ulcers, who was fully dependent on staff and in a persistent vegetative state, was not repositioned every two hours as required by the care plan and facility policy. Observations showed the resident remained on the same side for over three and a half hours, and staff confirmed the lapse in care, despite clear interventions and use of a low air loss therapy mattress.
Two residents requiring ventilator and oxygen support were observed with oxygen tubing resting on the floor, contrary to infection control policies. Both residents had significant respiratory conditions and care plans aimed at preventing infection. Staff, including the RT, IP, and DON, acknowledged that tubing on the floor was an infection control issue.
A resident with multiple medical conditions had a physician's order for 1% hydrocortisone cream without a stop date, allowing indefinite use. The consultant pharmacist identified this during a monthly medication regimen review and recommended adding a stop date or discontinuing the medication. Despite this, staff did not clarify the order with the physician, and the recommendation was not acted upon, contrary to facility policy.
A resident with multiple medical conditions received several scheduled medications late and without required vital sign checks prior to administration. An LVN administered the medications via G-tube hours after the scheduled time, did not notify supervisory staff or the physician about the delay, and failed to assess blood pressure and heart rate immediately before giving antihypertensive medication, as required by physician orders. These actions resulted in a medication error rate of 25%, exceeding the acceptable threshold.
A facility failed to create a person-centered care plan for a resident with major depressive disorder. Despite the resident's diagnosis being noted in the MDS, the care plan did not address depression, and staff confirmed the absence of necessary behavioral monitoring. The facility's policy mandates comprehensive care plans, which were not implemented in this case.
A facility failed to conduct weekly skin assessments for a resident with MASD, as required by their care plan. The resident, with multiple health issues, had their condition worsen to an unstageable pressure injury with necrotic tissue. The facility's policy required a comprehensive care plan, which was not followed.
A mobile linen cart was found uncovered and unattended in a hallway, exposing linens and violating the facility's infection control policies. Staff interviews confirmed the requirement to keep linen carts covered to prevent infection spread. The facility's policies mandate protection of clean linen during transport and storage.
A facility failed to develop a care plan for a resident with a stage four pressure injury on the left trochanter, despite the resident's complex medical conditions and dependency on staff for daily activities. The absence of a care plan was confirmed by the DON and was contrary to the facility's policy requiring comprehensive, person-centered care plans.
The facility failed to conduct background checks for an LVN and a CNA before hiring, as required by their policy to prevent abuse, neglect, and exploitation. This oversight was discovered during a review of employee files, where the checks were missing, and a search with the OIG system found no results. The DON emphasized the importance of these checks to ensure resident safety.
A facility failed to document necessary diagnoses for a resident receiving psychotropic medications. The resident's MDS did not reflect compulsive hoarding disorder or anxiety, despite being prescribed Ativan and Prozac. The MDSN confirmed a miscoding error, and the DON acknowledged the oversight, which could lead to unnecessary treatment.
A resident on oxygen was found smoking in their room, but the facility failed to update the smoking care plan or document smoking education. Despite initial assessments indicating the resident did not smoke, a later assessment confirmed smoking habits. The facility's oversight increased the risk of negative outcomes to the resident's well-being.
Two residents requiring substantial assistance with ADLs were neglected in their care. One resident was left in a soiled incontinence brief for 45 minutes despite calling for help, while another had a dry flaky substance around the eye that was not cleaned overnight. Staff were aware but did not provide timely assistance, citing reasons such as being on break. The facility's policies emphasize the importance of providing necessary care, but these were not followed, leading to neglect.
A resident with major depressive disorder was not provided necessary behavioral health care, as the facility failed to monitor and report symptoms of depression, update care plans, or ensure visits from mental health professionals. Despite known depressive symptoms, the resident was not systematically monitored or receiving medication, leading to unmanaged behavioral health needs.
The facility failed to provide sufficient nursing staff, resulting in delayed care for two residents who required assistance with personal care. CNAs reported being overburdened with assignments, making it difficult to respond promptly to residents' needs. Observations and interviews confirmed that residents experienced delays in receiving help, and family members expressed concerns about staffing levels. Despite claims of stabilized staffing, the facility did not meet required staffing hours, impacting the quality of care.
The facility failed to properly store and label medications, including insulin and inhalation powders, leading to potential risks for residents. Medications were found expired or improperly stored in medication rooms and carts, and timolol eye drops were left unattended during administration.
The facility failed to maintain safe food storage and preparation practices, including improperly labeled and stored thickened milk and juice, unmonitored thaw dates for nutritional supplements, and a dirty, worn can opener blade. These deficiencies posed a risk of foodborne illness to residents.
A facility failed to maintain a functional audible call system, impacting prompt response to resident needs. A resident with significant mobility and health issues reported the system was broken, and staff confirmed the announcement feature had been non-functional for months. Observations showed inconsistency in the system's operation, and temporary measures were in place to address the issue.
A resident's privacy was compromised when an LVN failed to close the bedside curtain during medication administration, violating the resident's right to dignity and privacy. The resident, with intact cognition and requiring assistance for personal hygiene, was observed during this incident. Interviews confirmed the importance of privacy, and the facility's policy emphasized maintaining dignity and respect.
A facility failed to ensure a resident had legal documentation for a representative, potentially delaying care. The resident, with mental disorder and hypertension, had no legal documentation confirming Family Member 2 as their representative after Family Member 1 passed away. The DON stated the admission process should identify a responsible party, but this was not completed, risking delayed care.
A facility failed to implement a care plan for a high-risk resident by not providing floor mats as required, increasing the risk of falls. Despite the care plan's directive, observations showed the absence of floor mats, and staff interviews confirmed the oversight. The resident had severe cognitive impairment and required maximum assistance, highlighting the need for proper fall prevention measures.
A resident with severe cognitive impairment and a high fall risk experienced a fall, but the LTC facility failed to update the fall care plan as required by their policy. Despite the resident's history and recent fall, the care plan was not revised, increasing the risk of further incidents.
The nursing staff failed to provide necessary safety interventions for two residents, one with a history of falls and another with epilepsy, in an LTC facility. Despite care plans and physician's orders, floor mats were not placed for a resident at high fall risk, and padded side rails were not provided for a resident with seizures. Observations and interviews confirmed these deficiencies, highlighting a lack of adherence to facility policies for fall prevention and bed safety.
A resident with multiple health conditions, including ESRD and diabetes, did not receive a required quarterly nutritional assessment, as confirmed by the RD, DS, and DON. The facility's policy mandates such assessments to ensure residents' nutritional needs are met, but the last assessment was conducted shortly after admission, with no follow-up documented.
A resident with a PICC line for Vancomycin administration had their dressing unchanged for nine days, contrary to the facility's policy of changing it every seven days. This oversight was acknowledged by a nurse and confirmed by the DON, highlighting a risk of infection due to non-compliance with the dressing change schedule.
The facility failed to ensure CNAs were competent in identifying fall risks, as evidenced by two CNAs' inability to recognize a yellow star indicating a high fall risk for a resident with severe cognitive impairment. Despite the facility's policy, there was no in-service training on fall prevention, leaving a gap in staff education and competency monitoring.
Two residents in a facility were affected by medication administration deficiencies. One resident with epilepsy did not receive the correct dose of divalproex ER due to a lack of 250 mg tablets, risking potential seizures. Another resident did not receive prescribed pyridoxine (vitamin B6) due to it being out of stock, risking vitamin deficiency. The facility's policy requires medications to be administered as prescribed, but these guidelines were not followed.
A facility failed to limit a PRN order for Lorazepam to 14 days for a resident with generalized anxiety disorder, as required by policy. The resident's physician's order lacked a stop date, leading to potential overmedication. Interviews with the RN and DON confirmed the oversight and acknowledged the risk of adverse effects due to non-compliance with the facility's psychotropic medication policy.
A long-term care facility failed to maintain a medication error rate below 5%, resulting in a 12.9% error rate. Two residents were affected: one did not receive the correct dose of divalproex ER for seizures due to a pharmacy order oversight, and another received metformin late and incorrect doses of other medications due to stock issues and administration errors. These failures were against the facility's medication administration policy.
A resident's food preferences were not updated or honored, leading to decreased meal satisfaction and caloric intake. Despite documented preferences for juice and milk and dislikes for certain foods, the resident received meals that did not align with their preferences. The Dietary Supervisor admitted that preferences were accidentally removed during a menu update, and the facility's policy to identify food preferences upon admission was not followed.
A facility failed to establish a contract and provide orientation for a cosmetologist who provided services to residents, including a resident with Alzheimer's and dementia. The cosmetologist, who was not employed by the facility, entered a resident's room without knocking or ensuring privacy. Interviews revealed no contract or vendor file existed, and it was unclear if the cosmetologist held a valid license. The facility's policy required all vendors to have a contract and undergo a 10-hour orientation, which was not completed.
The facility failed to ensure proper fit testing for staff using Medline N95 respirators, as several CNAs and LVNs were observed wearing these without being fit-tested. The Infection Preventionist confirmed the lack of fit testing, which is required by facility policy when changing respirator models. This deficiency was noted during a COVID-19 outbreak, highlighting the potential risk of exposure to airborne diseases.
A resident with respiratory conditions was not offered flu, pneumonia, and COVID-19 vaccines, despite being cognitively intact and capable of making her own decisions. The facility sought consent from the resident's family member, who refused the vaccines, contrary to the resident's wishes. The facility's policies required offering these vaccines to all residents, but the resident was not directly asked, leading to a deficiency in care.
A resident with dementia entered another resident's room at night and kissed them on the cheek, causing the resident to feel nervous and violated. Despite the incident occurring near the nursing station, no staff observed the event. The facility's policy defines such actions as non-consensual sexual contact.
A resident with dementia wandered into another resident's room and kissed them due to inadequate supervision. Despite having a care plan, the resident was not properly monitored, leading to the incident. Staff interviews revealed lapses in supervision, as the resident's room was near the nursing station, yet no staff observed the resident leaving.
The facility failed to maintain clean and sanitary fall mats in two residents' rooms, potentially exposing them to germs and infection. A resident with severe memory problems and another who was cognitively intact both had soiled fall mats, which were not cleaned by housekeeping. The facility's maintenance logbook lacked records of cleaning the mats, and the facility's cleaning policy was not followed.
The facility failed to ensure that their acting Infection Preventionist (IP) had accessible certification or training records in infection prevention and control. The Director of Staff Development, acting as the IP, could not provide a certificate despite claiming to have one. The facility's policies required specialized training, but the absence of documentation posed a risk to the infection prevention and control program.
Failure to Provide Required Abuse-Prevention In-Service Before CNA Returned to Direct Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy requiring appropriate in‑service training on resident rights and abuse prevention prior to staff having direct-care responsibilities. A resident admitted with diagnoses including diverticulitis, muscle weakness, dysphagia, depression, and colostomy status had documented cognitive capacity to understand and make decisions and required moderate to maximum assistance with ADLs. On a specified date, progress notes documented that this resident reported an allegation of abuse involving a CNA on the night shift. According to the resident’s report in the progress notes, the CNA allegedly woke the resident aggressively, threw two towels on the resident’s chest and another towel on the colostomy site, and turned and pulled the resident while providing incontinence care. The resident further alleged that the CNA made arm gestures with two closed fists and stated that if the resident spoke up about what happened, the resident would be hit, causing the resident to feel afraid of the CNA. The facility initiated an investigation and suspended the CNA pending the outcome, as reflected in the facility’s 5‑day conclusion of the facility‑reported incident. Record review showed that the CNA returned to work and provided resident care on a later date, as indicated by the time sheet. The Quality Assurance Nurse’s in‑service record for the CNA was dated after the CNA had already returned and provided care. In interviews, the Quality Assurance Nurse confirmed that he did not provide an in‑service to the CNA prior to the CNA resuming resident care, and the Director of Staff Development acknowledged she was responsible for providing one‑on‑one in‑service training before the CNA provided care but had not done so. The Administrator confirmed that the CNA was called back to work after the investigation was concluded and that in‑service training was not completed before the CNA’s shift, contrary to the facility’s policy requiring staff training on preventing, recognizing, and reporting abuse, and on resident dignity and respect, prior to having direct-care responsibilities.
Failure to Assess and Address Behavioral Health Needs After Alleged Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with depression and chronic anxiety received necessary behavioral health care and services following an alleged abuse incident. The resident was admitted with diagnoses including HTN, hyperlipidemia, depression, a colostomy, and a gastrostomy, and had intact cognition and decision-making capacity. Physician orders dated 10/23/2025 included a psychology consult and treatment as needed, and the resident’s care plan identified a psychosocial well-being problem related to a language barrier, with interventions including consultations with pastoral care, social services, and psych services. On 1/1/2026, the resident reported an allegation of abuse involving a CNA on the night shift. According to nursing progress notes, the resident stated that the CNA woke her aggressively, threw towels on her chest and colostomy site, pulled and turned her while providing care, and made arm gestures with two closed fists while telling her that if she spoke up about what happened she would be hit. The resident reported feeling afraid of this CNA. Subsequent physician documentation on 1/5/2026 noted that the resident, who had a chronic anxiety disorder per her husband, experienced increased nighttime anxiety and was afraid to fall asleep after this interaction. A progress note on 1/8/2026 documented that the resident stated she did not feel safe. Despite these documented changes in the resident’s emotional and behavioral status, the facility did not complete a behavioral assessment or change-of-condition assessment related to the 1/1/2026 incident. The Social Services Supervisor confirmed that trauma assessments are to be done on admission, quarterly, and at change of condition, and acknowledged that no behavioral assessment was done for the resident’s change in condition on 1/1/2026 and that there were no psychologist progress notes for the resident. The MDS Coordinator also stated there were no behavioral assessments done for the resident for 1/1/2026. The Quality Assurance Nurse described that, in general, an abuse allegation should trigger emotional distress monitoring, psych evaluation, social services consultation, and care plan updates when a resident continues to feel unsafe, but the record showed the resident’s increased anxiety and expressed lack of safety were not identified and addressed through care-planned behavioral health interventions. The facility’s own policies on behavioral assessment, trauma-informed care, and comprehensive person-centered care planning require identification, documentation, and interdisciplinary evaluation of new or changing behavioral symptoms and revision of the care plan when there is a significant change in condition, which did not occur in this case. During interviews, the Social Services Supervisor reported that the resident had made remarks about certain people of different ethnicities being loud, harmful, and unfriendly, and that the resident was not comfortable with certain staff of a different ethnicity, suggesting possible past trauma, but no related behavioral or trauma-focused assessment was documented after the incident. The DON stated she was not aware that the resident had reported not feeling safe on 1/8/2026 and indicated that the nurse should have notified the physician of this statement. Overall, the facility failed to recognize and assess the resident’s increased anxiety and fear following the alleged abuse, failed to initiate required behavioral assessments or a documented change-of-condition process, and failed to implement or document appropriate behavioral health and psychological services as outlined in the resident’s orders and the facility’s policies.
Failure to Promptly Assess and Initiate CPR for an Unresponsive Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff promptly assessed and initiated CPR for a resident who was a documented full code. The resident had severe cognitive impairment, dysphagia, dementia, COPD, a feeding tube, and a POLST and physician order directing that CPR and full treatment be provided to prolong life by all medically effective means. On the day of the incident, a visiting family member of the resident’s roommate brought cookies into the room. After the roommate requested cookies, the visitor fed a cookie to the cognitively impaired resident without consulting staff, despite the resident being on a pureed diet and unable to safely swallow solid foods. Shortly thereafter, the visitor observed the resident shaking, pale, and choking, and called for help. CNA1 responded and found the resident sitting up in bed, pale to bluish, with eyes open and wide, food running from the mouth, no movement, no gasping, no coughing, and no reaction to touch or to a finger sweep of the mouth. CNA1 reported that the resident did not blink, move, push back, or show any rise and fall of the chest. Despite recognizing these signs and being BLS certified (though her prior certificate was expired and her most recent certificate had been issued without her actually taking the class), CNA1 did not check for responsiveness in the prescribed manner, did not check for a pulse, and did not initiate CPR. Instead, she began performing the Heimlich maneuver two to three times and then, with RNA1, transferred the resident from the bed to a chair to continue the Heimlich. RNA1 and LVN1 each entered the room after hearing that a patient was choking. Both acknowledged that they did not assess the resident for responsiveness or check for a pulse before performing or continuing the Heimlich maneuver. RNA1 stated he did not have time to check for a pulse and focused on positioning the resident and performing abdominal thrusts, first in bed and then in a chair. LVN1 stated she was told the resident was choking and immediately performed the Heimlich maneuver without checking for breathing or a pulse, later acknowledging that CPR may have been delayed because the pulse was not checked. Multiple staff, including CNA2 and the DON, observed the resident as unresponsive, pale, not moving, and not alert, yet none of the first responders checked the resident’s pulse or initiated CPR at that time. RT1 arrived to find the resident sitting in a chair, appearing lifeless, not breathing, and without the universal sign of choking. RT1 checked the resident’s pulse, found none, and instructed staff to return the resident to bed and start CPR. Only at that point was CPR initiated. Interviews with the DON and Medical Director confirmed that facility policy and standard CPR protocols required that, upon finding an unresponsive resident, staff should immediately assess responsiveness, check for breathing and pulse, and, if no pulse is found, initiate CPR without delay. The facility’s own CPR policy required assessment of respirations and heartbeat, activation of emergency services, and initiation of CPR in the absence of a palpable pulse. The surveyors determined that CNA1, RNA1, and LVN1 failed to follow these required steps, resulting in a delay in CPR for a full-code resident who was unresponsive, not moving, and without a pulse when first found.
Removal Plan
- Implement a QAPI Performance Improvement Project (PIP) regarding CPR with return demonstrations.
- Educate all nurses on the procedure for initiating CPR and issue CPR certifications.
- Conduct CPR drills.
- Do not permit nurses to work without a CPR card until certification is completed.
- Audit residents' medical charts and identify residents who do not have a POLST.
Failure to Control Visitor Food and Supervise Resident on Pureed Diet Resulting in Choking Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident on a pureed gratification diet received food consistent with the ordered diet and to implement accident-prevention measures related to outside food brought by visitors. The resident had diagnoses including dysphagia oropharyngeal phase, dementia, prior pneumonitis due to inhalation of food and vomit, COPD, and required enteral feeding with only a pureed texture diet ordered for oral gratification. The resident’s care plan identified a risk for aspiration related to dysphagia but contained no nursing interventions addressing dysphagia, aspiration precautions, or the pureed diet. The Director of Nursing stated that each diagnosis required a specific care plan with interventions such as aspiration precautions, diet type, monitoring swallowing, and proper positioning, and acknowledged that this resident’s care plan did not include such interventions. The facility also failed to implement and operationalize its policy on Foods Brought by Family/Visitors. The written policy required family and visitors to inform nursing staff when foods were brought for a resident and prohibited sharing such foods with other residents. The DON stated that staff were supposed to tell family and visitors to check with nurses when bringing food, but there was no documentation of licensed nurses checking outside food, no education given to visitors regarding outside food, and no signs posted for visitors about the policy or about not sharing food with other residents. A family member visitor reported that staff saw her bring food into the facility almost weekly for another resident and never said anything, and that staff did not explain any rules or policies on outside food or what foods were safe or unsafe. On the day of the incident, a visitor brought chocolate chip and oatmeal cookies for the roommate of the resident on a pureed diet. While feeding a cookie to the roommate, the visitor reported that the resident on the pureed diet repeatedly asked for a cookie. The visitor then gave the resident a chocolate chip cookie without asking any staff if it was appropriate. After approximately five to ten minutes, the visitor observed the resident shaking, pale, and appearing to choke, and called for help. A CNA entered and found the resident in bed, unresponsive, pale, with food running from the mouth, and removed pieces of cookie from the mouth with a finger sweep. Additional staff, including a restorative nursing assistant, LVN, and respiratory therapist, responded and attempted the Heimlich maneuver, suctioning, and CPR. The resident was ultimately found to have no pulse and was later pronounced dead by paramedics. The facility’s failure to ensure supervision, environmental safeguards, and enforcement of the outside food policy allowed unsafe, non-pureed food to be provided to a resident with severe cognitive impairment and high aspiration risk, resulting in the resident receiving food inconsistent with the ordered pureed diet and choking. Family interviews further showed that the resident’s responsible party was not informed of any policy for outside food or steps to prevent the resident from being fed unsafe food from outside. This family member stated there were no signs or measures in place to remind the resident not to eat or to tell others not to feed him, despite his poor memory and history of ingesting unsafe substances, including laundry detergent prior to admission. The DON confirmed that staff were informed of residents on aspiration precautions only verbally at morning huddles and that there were no posted signs for visitors regarding food brought by family or visitors. The medical director and registered dietitian both confirmed that the resident was ordered a pureed texture diet due to dysphagia and that only pureed foods should have been given, with the expectation that families would be educated and would not give food without consulting nurses. These combined failures in care planning, visitor education, supervision, and enforcement of the outside food policy led directly to the resident being given a regular-texture cookie, choking, and dying.
Removal Plan
- The Administrative Consultant educated the Administrator (ADM) and the Director of Nursing (DON) on the policy regarding Food Brought by Family/Visitors.
- The DON conducted in-services for all staff on the policy regarding Food Brought by Family/Visitors.
- A third-party software sent text and email messages to all residents and their responsible parties educating them to inform nursing staff when foods are brought to the facility for a resident and instructing them not to share/distribute food to other residents.
- The facility posted signage throughout the facility regarding the Food Brought by Family/Visitor policy.
- The receptionist or designee encouraged visitors to sign in on the Visitor Log and indicate whether they brought food/drinks; if food/drinks were brought, LVNs ensured the items were appropriate for the resident’s prescribed diet and educated visitors not to share food/drinks with other residents.
- The Registered Dietitian posted a Dietary Log outside the kitchen for staff to cross-check special requests from residents/staff/family to ensure requests follow physician dietary orders posted in the kitchen.
- The Interdisciplinary Team identified residents with mechanically altered diets and updated their care plans.
Failure to Develop Individualized Dysphagia Care Plans for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement specific, individualized person-centered care plans for residents with dysphagia. For Resident 1, the admission record showed diagnoses including oropharyngeal dysphagia, dementia, prior pneumonitis due to inhalation of food and vomit, COPD, and the need for GT care. The care plan report dated 9/15/2025 identified a risk for aspiration related to dysphagia but contained no nursing interventions. Physician orders later directed enteral feeding with Jevity 1.5 at a specified rate and duration, and a pureed diet for oral gratification, but these orders were not translated into a detailed dysphagia care plan with measurable interventions. During interview, the DON acknowledged that Resident 1’s care plan lacked nursing interventions to address dysphagia and the pureed diet, despite the resident’s diagnosis and aspiration risk. For Residents 2, 3, and 4, surveyors found similar omissions. Resident 2 was admitted with diagnoses including aphasia, dysphagia following cerebral infarction, dementia, and adult failure to thrive, and had severe cognitive impairment per the MDS. The MDS documented extensive assistance needs for ADLs, and a physician order directed a controlled carbohydrate, pureed texture, thin consistency diet. Resident 3 was admitted with gastrostomy, dysphagia, and dementia, had moderate cognitive impairment, was dependent for multiple ADLs, and had orders for a fortified pureed thin diet. Resident 4 was re-admitted with aphasia and dysphagia following cerebral infarction, had moderate cognitive impairment, required substantial to total assistance for eating and other ADLs, and had orders for a fortified/high protein, no added salt, pureed thin diet. Despite these diagnoses and diet orders, record review showed that none of these three residents had a specific dysphagia care plan initiated upon admission or thereafter. Multiple staff interviews confirmed the absence of required dysphagia care plans and clarified facility expectations. The DON, LVN 2, and the Quality Assurance Nurse each stated that every resident diagnosis and identified problem should have a care plan, that care plans are individualized guides for treatment, and that dysphagia care plans should include interventions such as diet orders, aspiration precautions (e.g., upright positioning, head of bed elevation), monitoring for coughing and shortness of breath, monitoring swallowing, speech therapy/swallow evaluations, and education for residents and families. They each acknowledged that Residents 2, 3, and 4 had dysphagia diagnoses and pureed diet orders but did not have dysphagia care plans initiated on admission. The facility’s written policy on comprehensive person-centered care plans required measurable objectives and timetables for each resident’s needs, ongoing assessment, and revision of care plans with changes in condition or orders, but these requirements were not met for the four residents with dysphagia. Staff further stated that the lack of dysphagia care plans created a potential for increased risk of aspiration and pneumonia because nurses would not know the specific plan of care, treatment, and interventions needed for these residents’ swallowing difficulties. The DON, LVN 2, and the QAN each articulated that without a dysphagia care plan, nurses lacked clear guidance on necessary precautions and monitoring. This combination of documented diagnoses, diet orders, and acknowledged facility policy, contrasted with the absence of corresponding individualized dysphagia care plans and interventions, formed the basis of the cited deficiency under the requirement to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for each resident. The facility’s own policy and staff descriptions emphasized that care plans should reflect recognized standards of practice, include services to attain or maintain the highest practicable well-being, and be updated on admission, quarterly, with changes in condition, and with new physician orders. Despite this, the care plan reports for all four residents lacked a specific dysphagia problem and associated interventions, even though each resident had documented swallowing disorders and specialized diet or feeding orders. The survey findings therefore centered on the gap between policy and practice: the facility did not translate known dysphagia diagnoses and physician orders into individualized, measurable care plan interventions for these residents, as confirmed by record review and staff interviews.
Failure to Complete Required Staff Competency Evaluations
Penalty
Summary
The facility failed to conduct required staff competency evaluations for two of three sampled certified nursing assistants (CNAs), as mandated by its own policies and procedures. Specifically, one CNA did not have a performance skills checklist in their employee file, and another CNA, who was hired several months prior, did not have a documented performance evaluation. The Director of Staff Development (DSD) acknowledged that she was new to the system and was unaware of when the skills checklist for one CNA was performed, and also confirmed that the performance evaluation for the other CNA had not been completed. The DSD stated that performance evaluations are generally performed ninety days after hire and then annually, but these were missing for the two CNAs in question. The Director of Nursing (DON) confirmed that an audit of employee files had been conducted, and without the required performance evaluations and skills checklists, the facility would not be able to determine if staff lacked knowledge or required additional training. The facility's policies require that job performance be reviewed at the end of a 90-day probationary period and at least annually thereafter, and that competency requirements and training for nursing staff are established and monitored by nursing leadership. The absence of these evaluations and documentation for the two CNAs represents a failure to ensure that staff have the appropriate competencies to care for residents as required by facility policy.
Failure to Maintain Clean, Odor-Free, and Homelike Environment
Penalty
Summary
Facility staff failed to maintain a clean, odor-free, and homelike environment for a resident with severe cognitive impairment and total dependence on staff for daily living activities. Observations revealed a strong urine odor around the resident's bed and room entrance, as well as a dirty, wet, and smelly gray fall mat at the right side of the bed. The fall mat was noted to have foot prints, scuff marks, and a drying sticky wet mark. A Certified Nursing Assistant (CNA) acknowledged the strong urine odor and the unclean condition of the fall mat, attributing the situation to not having had a chance to change the resident's incontinence brief due to being occupied with other residents. The resident involved had multiple medical diagnoses, including diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, gastrostomy, hypertension, and dysphagia. The Minimum Data Set assessment indicated the resident was totally dependent on staff for bed mobility, dressing, toileting, bathing, and personal hygiene. The facility's policy required a safe, clean, comfortable, and homelike environment with pleasant, neutral scents, but these standards were not met in this instance.
Failure to Administer Prescribed Enteral Nutrition Due to Pump Malfunction
Penalty
Summary
Facility staff failed to administer the prescribed amount of enteral nutrition to a resident with multiple complex medical conditions, including diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, gastrostomy, hypertension, and dysphagia. The resident was totally dependent on staff for all activities of daily living and had severe cognitive impairment. The physician's order specified that the resident should receive diabetic source enteral feeding at 1.2 calories per milliliter, 80 ml per hour for 20 hours, totaling 1600 ml or 1920 calories, with a scheduled pause from 8 am to 12 pm. Observation at the resident's bedside revealed that the enteral feeding pump was turned off, and only 200 ml of formula had been infused over a 12-hour period, instead of the ordered 960 ml. The feeding bottle had been hung the previous evening, and the discrepancy was confirmed during an interview with the DON, who acknowledged the resident did not receive the required nutrition due to the pump not functioning as intended. The facility's policy required adequate nutritional support through enteral nutrition as ordered, but this was not followed in this instance.
Medication Administration and Controlled Substance Documentation Deficiencies
Penalty
Summary
The facility failed to ensure safe medication administration and accurate accountability of controlled medications for four residents. For one resident with hypertension and dependence on a ventilator, blood pressure medication (Amlodipine) was administered late on six occasions, and the physician was not notified of the delays. Additionally, the nurse did not check the resident's blood pressure immediately prior to administering the medication, as required by the physician's order. The facility's policy required medications to be administered within one hour of the scheduled time and for vital signs to be checked if necessary, but these procedures were not followed. For the same resident, there was a discrepancy between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR) for a dose of Oxycodone/APAP, a controlled medication. The CDR indicated a dose was removed and administered, but the MAR lacked documentation of administration and pain assessment. The nurse responsible did not document the administration or the resident's pain level, contrary to facility policy, which requires immediate documentation of all medications administered, including PRN effectiveness. Another resident with epilepsy and anoxic brain damage had discrepancies in the documentation and administration of Ativan, a controlled medication. The CDR, MAR, physician's order, and pharmacy label did not match, and the inventory of the medication was inconsistent. The resident was not reassessed for effectiveness of PRN Ativan within the required 30 minutes, and the physician's order lacked a maximum dose and clear instructions for when to notify the physician. Additionally, two residents with diabetes received insulin injections in the same sites repeatedly, without proper rotation, despite care plans and facility policy requiring site rotation to prevent complications.
Failure to Follow RCS Diet Guidelines During Meal Service
Penalty
Summary
Staff failed to follow the facility's Reduced Concentrated Sweets (RCS) diet guidelines for residents requiring blood sugar control. On the specified lunch service, both regular and RCS diet trays were observed receiving garlic bread, despite the facility's food portioning and serving guide indicating that garlic bread should not be served to residents on the RCS diet. The lunch menu and the serving guide clearly differentiated between the regular and RCS diets, with the RCS diet omitting garlic bread and providing a reduced portion of dessert. During interviews, the dietary aide responsible for assembling trays confirmed that garlic bread was added to both regular and RCS trays, acknowledging that this was not in accordance with the diet spreadsheet and could affect blood sugar levels. The dietary supervisor and registered dietitian also confirmed that the RCS diet should not have included garlic bread and that staff are required to follow the diet spreadsheets to ensure residents receive the correct nutrition per diet orders. Facility policy on controlled-carbohydrate diets emphasized the importance of following specified portion sizes and meal components for blood sugar management.
Improper Cleaning and Storage of Kitchenware
Penalty
Summary
Surveyors observed that dietary staff failed to ensure proper cleaning and sanitization of resident cups, trays, and dishes in the kitchen. During the inspection, a dietary aide was seen removing trays, cups, and bowls from the dishwashing machine and storing them to air dry, despite visible food particles and residue remaining on the items. Some trays also had tape stuck to them, and the counter where clean dishes were placed was covered with food particles, including grains from breakfast cereal. The dietary aide admitted to returning visibly dirty dishes to be rewashed but did not notice other soiled items that were stored as clean. The dietary supervisor confirmed the presence of food residue and tape on the trays and acknowledged that the counter was contaminated with food particles from the dishes. Further interviews revealed that the dishwasher operator had not adequately scraped or rinsed the dishes before loading them into the dishwashing machine, resulting in grits and other food debris remaining on the trays and bowls after washing. The facility's policy required all utensils, counters, shelves, and equipment to be kept clean and in good repair, and the FDA Food Code specified that food debris should be scraped and, if necessary, pre-flushed or scrubbed before washing. These procedures were not followed, leading to improper cleaning and storage of kitchenware used by residents.
Failure to Complete Pre-Employment Background Checks for Direct Care Staff
Penalty
Summary
The facility failed to ensure that three out of ten staff members, including a registered nurse, a licensed vocational nurse, and a certified nurse assistant, had background checks completed prior to their employment. Review of employee files revealed that background checks for these staff members were either conducted years after their hire dates or only after a random review, rather than before employment as required by facility policy. The Director of Staff Development confirmed that some background checks were missing or delayed, and the Director of Nursing acknowledged the risk posed by employing staff without completed background checks. An incident involving a resident who required assistance with personal care, and who had diagnoses including gout and toxic encephalopathy, highlighted the deficiency. The resident reported being handled roughly by a CNA during incontinent care, leading to an abuse investigation. It was discovered that the CNA involved had not undergone a background check prior to hire. Facility policies reviewed indicated that background checks were to be completed before employment, but this was not followed in these cases.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for resident needs by not ensuring that the call light was within reach for two residents. For one resident with limited mobility, muscle weakness, pressure-induced deep tissue injuries, and a history of falls, multiple care plans specified that the call light should be within easy reach at all times and that the resident should be encouraged to use it for assistance. However, during an observation, the call light was found above the resident's head, resting on the mattress and facing the back wall, making it inaccessible. The resident was unable to call for assistance after an incontinent episode until staff intervened. Another resident, diagnosed with pressure ulcers and functional quadriplegia, also had care plans indicating the need for the call light to be within reach and for staff to encourage its use. During observation, the call light was clipped to the top of the mattress and left dangling off the side of the bed, again not within the resident's reach. Staff confirmed that if the call light was not accessible, the resident could not call for help. The assigned CNA was not present at the time, but other CNAs were reportedly available in the hallway. Interviews with staff, including the DON, confirmed that nursing staff are expected to ensure call lights are in place at the beginning of each shift and that call lights should always be accessible to residents. The facility's policy also requires that the call light be accessible to residents when in bed. Despite these policies and care plan interventions, the call lights were not within reach for the two residents at the time of observation.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident whose Medicare Part A skilled services were ending. The resident, who was admitted for acute kidney failure and was moderately cognitively impaired, required substantial assistance with daily activities. According to the facility's records, the resident's last covered day for Medicare Part A services was documented, and the discharge was planned with the resident returning home with home health services. However, there was no evidence that the NOMNC was issued to the resident as required. During interviews and record reviews, both the Business Office Administrator and the Director of Nursing were unable to locate the NOMNC or determine if the discharge was beneficiary-initiated. The facility's policy required that a NOMNC be issued at least two calendar days before Medicare benefits end, but the documentation and staff interviews confirmed that this did not occur for the resident in question.
Failure to Reposition Bedbound Resident with Pressure Ulcers Every Two Hours
Penalty
Summary
A deficiency was identified when a resident with multiple pressure ulcers, including Stage III and Stage IV wounds, was not repositioned every two hours as required by their care plan and facility policy. The resident, who was in a persistent vegetative state and fully dependent on staff for all activities of daily living, was observed lying on her left side for over three and a half hours without being repositioned. Multiple staff interviews confirmed that the resident should have been turned at least every two hours to prevent further skin breakdown and to comply with the care plan interventions. The resident's medical history included acute and chronic respiratory failure, non-traumatic subarachnoid hemorrhage, COPD, ventilator dependence, and persistent vegetative state. The care plan specifically addressed the need for frequent repositioning due to the presence of pressure ulcers on several body sites, and the use of a low air loss therapy mattress was ordered for wound management. Despite these interventions, direct observations and staff interviews revealed that the resident was not repositioned as required, and staff acknowledged the lapse in care. Facility policies on prevention of pressure injuries and repositioning outlined the necessity of individualized repositioning schedules, with a minimum standard of every two hours for bed-bound residents. The Director of Nursing and other staff verified that the resident had not been repositioned according to the care plan, and that simply placing a pillow under the resident did not constitute a proper repositioning. The failure to follow the established care plan and facility policy resulted in the identified deficiency.
Oxygen Tubing Found on Floor for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents who required ventilator and oxygen support. For both residents, observations revealed that oxygen tubing connected to their ventilators was resting on the floor. Resident 29, who was in a persistent vegetative state with chronic respiratory failure, tracheostomy, and under hospice care, was observed with oxygen tubing touching the floor in their room. Resident 63, who was ventilator-dependent with chronic respiratory failure, COPD, ALS, and had mental capacity, was also observed with oxygen tubing on the floor. Both residents had care plans with goals to remain free of infection, and physician orders for oxygen therapy and ventilator support. During interviews, the respiratory therapist acknowledged the tubing was on the floor and agreed it could be an infection control issue, stating the tubing would be replaced. The infection preventionist and DON also confirmed that oxygen tubing touching the floor constituted an infection control problem. The facility's infection control policy required maintaining a safe and sanitary environment to prevent and control infections, and staff were to be trained on these practices. Despite these policies, the observed practice of allowing oxygen tubing to rest on the floor represented a failure to adhere to infection control standards.
Failure to Clarify Physician Order for Topical Steroid After Pharmacist Recommendation
Penalty
Summary
The facility failed to clarify a physician's order for hydrocortisone cream as recommended by the consultant pharmacist during the monthly medication regimen review for one resident. The resident had been readmitted with multiple diagnoses, including Type 2 diabetes, rash, schizophrenia, dementia, and psychosis. The physician's order directed the use of 1% hydrocortisone cream to the right side of the nose and face every six hours as needed for itching, but did not include an end date, allowing for indefinite use. During the consultant pharmacist's medication regimen review, it was noted that the order for hydrocortisone cream lacked a stop date. The pharmacist recommended that the topical steroid be used for no more than four weeks at a time and advised facility staff to request the physician to add a stop date or discontinue the medication. Despite this recommendation, the order remained unchanged and the cream continued to be available for indefinite use. Interviews with facility staff, including an LVN and the DON, confirmed that the pharmacist's recommendation was not acted upon. Both staff members acknowledged that recommendations from the consultant pharmacist should be communicated to the physician and followed up, but in this case, the order was neither clarified nor discontinued as advised. The facility's policy required that such recommendations be acted upon and documented, but this process was not completed for the resident in question.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Practices
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5%, as evidenced by seven medication errors out of 28 observed opportunities, resulting in a 25% error rate for one resident. The errors were identified during a medication administration observation for a resident with diagnoses including hypertension, ventilator dependence, and a gastrostomy tube. The resident required multiple medications to be administered via G-tube, with specific physician orders and parameters for administration, such as holding blood pressure medications if certain vital sign thresholds were not met. During the observed medication pass, a licensed vocational nurse prepared and administered eight scheduled morning medications several hours past the prescribed time without notifying a supervisor or the physician. The nurse did not check the resident's blood pressure or heart rate immediately prior to administering the antihypertensive medication, instead relying on vital signs taken four hours earlier. This was contrary to the physician's order, which required current vital sign assessment before administration. The nurse also failed to inform the nurse practitioner or physician about the delay in medication administration, as required by facility policy. Interviews with facility staff, including the nurse practitioner, registered nurse, director of nursing, and medical director, confirmed that the nurse should have checked the resident's vital signs immediately before administering the blood pressure medication and should have notified the physician about the late administration. Facility policy required medications to be given within one hour of the scheduled time and for staff to notify the physician if this was not possible. The failure to follow these procedures resulted in multiple medication errors for the resident.
Failure to Develop Care Plan for Resident's Depression
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident diagnosed with major depressive disorder. The resident, who was admitted with diagnoses including myopathy, schizophrenia, and major depressive disorder, was found to have no care plan addressing their depression. The comprehensive Minimum Data Set (MDS) indicated the resident was free of cognitive impairment and required assistance with bed mobility, transfer, and personal hygiene. Despite the diagnosis of depression being noted, the care plan revised on March 17, 2025, did not include measures to address this condition. During interviews, both a Licensed Vocational Nurse (LVN) and the MDS Nurse confirmed the absence of a care plan for the resident's depression. The LVN highlighted the need for a behavioral monitoring care plan to observe signs of depression, such as crying, lack of appetite, and refusal of care, which were not documented. The MDS Nurse acknowledged the lack of a care plan and stated that the issue should be discussed during the facility's quarterly interdisciplinary team meeting. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables, which was not implemented for this resident.
Failure to Implement Weekly Skin Assessments
Penalty
Summary
The facility failed to implement the care plan intervention of conducting weekly skin assessments for a resident, which was a requirement due to the resident's existing skin condition. The resident was admitted with multiple diagnoses, including visual loss, hypertension, morbid obesity, anemia, heart failure, and arrhythmia. The care plan, dated 11/14/24, specified weekly skin assessments due to moisture-associated skin damage (MASD). However, the facility did not perform these assessments for three consecutive weeks, as verified by the Director of Nursing (DON). The resident's condition worsened, with the MASD progressing to an unstageable pressure injury with necrotic tissue. The resident was at risk for unavoidable pressure injury due to complex medical conditions and episodes of noncompliance with care, including refusing turning, repositioning, and wound care. The facility's policy required a comprehensive, person-centered care plan with measurable objectives and timetables, which was not adhered to in this case.
Uncovered Linen Cart Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not ensuring that a mobile linen cart was covered while unattended. During an observation in the hallway outside the activity room, a mobile linen cart was found with its flap open, exposing the linen inside. This observation was confirmed during an interview with a Certified Nursing Assistant (CNA), who acknowledged that the cart should have been covered for infection control purposes. Further interviews with a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the linen cart should not be left uncovered to prevent the spread of infection. The Infection Preventionist (IP) also stated that uncovered linens could lead to the spread of infection and that staff had been trained to cover the carts. The facility's policy and procedure documents indicated that clean linen should be protected from dust and soiling during transport and storage, and that all personnel would be trained on infection control practices.
Failure to Develop Care Plan for Resident's Pressure Injury
Penalty
Summary
The facility failed to develop a care plan for a resident with a stage four pressure injury on the left trochanter. This deficiency was identified during a review of the resident's records and confirmed by the Director of Nursing (DON). The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, dysphagia, and cerebrovascular accident, was dependent on staff for activities of daily living and had severely impaired cognition. Despite these conditions, there was no care plan in place for the resident's significant wound, which required specific treatment with Santyl ointment as per physician's orders. The absence of a care plan for the resident's pressure injury was contrary to the facility's policy and procedures, which mandate the development and implementation of a comprehensive, person-centered care plan for each resident. This plan should include measurable objectives and timetables to address the resident's physical, psychosocial, and functional needs. The lack of a care plan for the resident's wound posed a risk of not providing appropriate, consistent, and individualized care, as confirmed by the DON during the survey.
Failure to Conduct Background Checks for Staff
Penalty
Summary
The facility failed to implement its policy and procedure titled 'Abuse, Neglect, Exploitation and Misappropriation Prevention Program' by not conducting background checks for two staff members, a Licensed Vocational Nurse (LVN 1) and a Certified Nurse Assistant (CNA 2), prior to their employment. This oversight was discovered during a review of employee files with the Director of Staff Development (DSD), where it was found that the background checks were missing from the files of these two staff members. The DSD confirmed that the background checks should have been present in the files but were not, and a subsequent search with the OIG background check system yielded no results for these individuals. The Director of Nursing (DON) stated that background checks are a prerequisite for hiring to ensure that employees do not have any legal issues that could pose a risk to resident safety and well-being. The facility's policy, dated April 2021, mandates conducting employee background checks as part of its commitment to protecting residents from abuse, neglect, exploitation, or misappropriation of property by anyone, including facility staff. The failure to adhere to this policy increased the risk to the health and rights of the residents in the facility.
Failure to Document Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident had current documented diagnoses to support the administration of psychotropic medications. The resident was admitted with a diagnosis of dementia and muscle weakness. However, the care plans indicated the use of Ativan for anxiety and Prozac for compulsive hoarding disorder, neither of which were documented as active diagnoses in the resident's Minimum Data Set (MDS). The MDS, a federally mandated resident assessment tool, did not reflect diagnoses of compulsive hoarding disorder, depression, or anger outburst, which were necessary to justify the prescribed medications. During interviews, the Minimum Data Set Nurse (MDSN) confirmed a miscoding error, acknowledging that new orders were discussed in clinical meetings but not accurately captured in the MDS. The Director of Nursing (DON) also confirmed that the MDS did not indicate the necessary diagnoses, which could lead to unnecessary treatment without proper documentation. The facility's policy required the MDS coordinator to ensure appropriate edits before transmitting MDS data, but this was not adhered to, resulting in the deficiency.
Failure to Update Smoking Care Plan for Resident on Oxygen
Penalty
Summary
The facility failed to ensure that a resident, who was administered oxygen, received care in accordance with professional standards of practice and the comprehensive person-centered care plan. The resident was found smoking in his room, and the smoking care plan was not updated or revised. This oversight increased the risk of a negative outcome to the resident's physical and psychosocial well-being. The resident had been admitted with diagnoses including hemiplegia, hemiparesis, depression, anxiety, and intellectual disability. Despite these conditions, the Minimum Data Set indicated the resident was cognitively intact, which was inconsistent with the list of diagnoses. The facility's records showed discrepancies in the resident's smoking status, with initial assessments indicating the resident did not smoke. However, a later assessment confirmed the resident was a smoker and used electronic cigarettes. The facility's smoking care plan included interventions such as explaining the facility's smoking policies and fire safety, but there was no documentation verifying these interventions were implemented. The facility's policy required re-evaluation of a resident's smoking status upon significant changes, but the care plan was not updated after the resident was found smoking in his room. An LVN acknowledged that the smoking care plan should have been updated and that the smoking education provided to the resident was not documented.
Neglect in Resident Care for ADLs
Penalty
Summary
The facility failed to protect two residents from neglect, as observed in the care of their activities of daily living (ADLs). Resident 77, who required substantial assistance with personal hygiene, was left in a soiled incontinence brief for 45 minutes despite calling out for help multiple times. The resident expressed feelings of being dirty, unimportant, and frustrated due to the lack of timely assistance. Observations revealed that both a CNA and an LVN were aware of the resident's calls for help but did not provide immediate assistance, citing reasons such as the assigned CNA being on lunch break. Resident 48, who was dependent on others for personal hygiene due to visual impairment and other medical conditions, was observed with a dry flaky substance around the right eye, which had not been cleaned since the previous night. The resident expressed discomfort and requested assistance to clean the eye. The CNA acknowledged the resident's need for total care and the necessity to clean the eye to prevent further discomfort or potential infection. The facility's policies on ADLs and abuse and neglect emphasize the importance of providing necessary care to maintain residents' hygiene and prevent neglect. However, the observations and interviews indicate a failure to adhere to these policies, resulting in neglect of the residents' needs. The Director of Staff Development and the Director of Nursing acknowledged the expectations for staff to respond to residents' needs and the potential consequences of neglect, such as skin breakdown and eye infections.
Failure to Provide Behavioral Health Care for Resident with Depression
Penalty
Summary
The facility failed to provide necessary behavioral health care for a resident diagnosed with major depressive disorder. The resident, who was admitted with multiple diagnoses including major depressive disorder, was not monitored for signs and symptoms of depression as outlined in their care plan. The care plan, which was supposed to include interventions such as monitoring and reporting acute episodes of sad feelings, was not updated or reviewed quarterly, and there was no evidence of monitoring or reporting to the physician as needed. The resident expressed feelings of frustration and sadness, which were not adequately addressed by the facility. Despite the resident's care plan indicating the need for psychologist visits every three weeks, there was no record of such visits or evaluations by a psychiatrist or psychologist. Interviews with staff revealed that the resident's depressive symptoms were known, but there was no systematic monitoring or documentation of these symptoms, and the resident was not receiving medication for depression. The facility's policy on behavioral assessment and monitoring was not followed, as the nursing staff failed to identify, document, and inform the physician about changes in the resident's mental status. The Director of Nursing acknowledged that the resident was not being monitored due to the absence of medication for depression and a lack of orders from a psychologist or psychiatrist. This oversight resulted in the resident's behavioral health needs being unmanaged, contrary to the facility's obligation to provide necessary care.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate and sufficient nursing staff to meet the needs of two residents, Resident 77 and Resident 39. Both residents experienced delays in receiving assistance for personal care needs, such as being cleaned and changed. Certified Nursing Assistants (CNAs) reported being assigned over 15 residents each, making it impossible to provide quality care. Observations and interviews revealed that Resident 77 was left calling for help to be changed, and staff were unable to respond promptly due to high workloads. Resident 77 was admitted with chronic osteomyelitis, abnormalities of gait and mobility, and congestive heart failure, requiring substantial assistance with activities of daily living. The resident was observed calling out for help to be changed, and staff were seen passing by without responding. Interviews with CNAs and Licensed Vocational Nurses (LVNs) confirmed that the facility was consistently short-staffed, leading to delays in responding to residents' needs and affecting the quality of care provided. Family members and staff expressed concerns about the facility's staffing levels, with reports of long wait times for phone calls and call lights. The Director of Staff Development acknowledged the potential impact of insufficient staffing on resident care, while the Director of Nursing admitted that the facility had not met required staffing hours in the subacute unit. Despite claims of stabilized staffing, the facility's policy indicated a need for sufficient nursing staff to ensure resident safety and well-being, which was not met in this instance.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and removal of undated and expired medications, specifically insulin, fluticasone-salmeterol, lansoprazole suspension, and gabapentin solution, as per manufacturer's requirements. This affected multiple residents across different medication storage areas, including the Station A Medication Room and various medication carts. Observations revealed that insulin vials and pens were either not labeled with an open date or were stored beyond their expiration dates, which could lead to ineffective treatment for residents with diabetes. In the Middle Medication Cart, several insulin products were found to be expired, including Insulin Lispro Kwik Pen, Basaglar Kwik Pen, Admelog SoloStar, and Humulin N KwikPen. Additionally, fluticasone and salmeterol inhalation powder was found to be expired. These medications were not removed from the cart as required, potentially compromising their effectiveness and safety for residents with conditions such as diabetes and respiratory issues. Furthermore, during medication administration, timolol eye drops were left unattended on a resident's bedside cart, posing a risk for misplacement or misuse. The facility's policy and procedure for medication labeling and storage were not adhered to, as medications were not stored in locked compartments or under proper conditions, and labels did not consistently include necessary information such as expiration dates and resident names.
Deficient Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. There was a carton of thickened milk stored in the refrigerator without an open date, and a carton of thickened apple juice was mislabeled with a use-by date that exceeded the facility's guidelines for fruit juice storage. Additionally, a peeled onion was improperly stored at room temperature in the bulk onion storage container, which should have been refrigerated. The Dietary Supervisor acknowledged these issues, stating that opened products should be marked and used within seven days according to facility guidelines. Furthermore, nutritional supplements labeled to be stored frozen and used within 14 days of thawing were not monitored for the correct thaw date. Thirty strawberry-flavored nutrition supplements were found in the refrigerator with different thaw dates, leading to uncertainty about their freshness. The Dietary Supervisor admitted to not knowing the real thaw date due to multiple dates being recorded and subsequently discarded the supplements. This oversight had the potential to cause foodborne illness among residents consuming these supplements. Additionally, a can opener blade in the kitchen was found to be dirty with sticky brown residue and was worn and nicked, making it difficult to clean properly. The Dietary Supervisor confirmed that the blade needed replacement as it could not be adequately cleaned and sanitized, posing a risk of contamination. The facility's policy on sanitization requires all equipment to be maintained in good repair and free from defects that could affect their use or cleaning, which was not adhered to in this instance.
Deficiency in Audible Call System Functionality
Penalty
Summary
The facility failed to ensure that the audible resident call system remained functional, which had the potential to prevent staff from answering call lights promptly. The call light for a specific room was not audible when pressed, as observed during the survey. A resident admitted with Guillain-Barre Syndrome, spinal stenosis, and muscle weakness, who was dependent on staff for mobility and at risk for pressure ulcers, reported that the call system was broken. The resident expected an automated voice announcement when the call light was activated, which was not functioning as intended. Interviews with staff revealed that the call light system was supposed to light up outside the room and announce the room number, but the announcement feature had not been working for about six months. Maintenance staff confirmed that while the light was visible on the panel across from the nurse's station and outside the room, the room number announcement was not audible. Observations on different days showed inconsistency in the audible system's functionality. The Director of Nursing emphasized the importance of both audible and visual systems working, while the Administrator mentioned that CNAs were stationed at the end of hallways to visually monitor call lights as a temporary measure.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to maintain dignity and privacy for Resident 63 by not closing the bedside curtain during medication administration. This incident was observed when the Director of Nursing (DON) instructed Licensed Vocational Nurse (LVN) 4 to assist LVN 3 with a medication pass. LVN 3 entered Resident 63's room with prepared medications but did not close the bedside curtain while administering them. This action violated the resident's right to privacy and dignity. Resident 63 was admitted to the facility with diagnoses including Type II Diabetes Mellitus and unspecified anemia. The resident had intact cognition and required assistance for personal hygiene. Interviews with the DON and LVN 4 confirmed the importance of closing the bedside curtain to ensure privacy and dignity, and it was noted that LVN 3 did not follow this protocol. The facility's policy on dignity, reviewed in August 2024, emphasized treating residents with dignity and respect, including maintaining privacy during care and treatment procedures.
Failure to Document Resident Representation
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 66, had legal documentation indicating that a family member was the resident's representative. This deficiency was identified during a review of the resident's records and interviews with facility staff. Resident 66 was admitted with diagnoses including an unspecified mental disorder and hypertension. The facility's records indicated that Family Member 1, who was initially responsible, had passed away, and Family Member 2 was to make decisions for the resident. However, there was no legal documentation in the resident's electronic chart to confirm Family Member 2 as the representative. During an interview, the Director of Nursing (DON) explained that the admission process should include identifying if a resident can represent themselves or if a responsible party is available. In the absence of a responsible party, the facility should contact the ombudsman or conservatorship. The lack of legal documentation for Resident 66's representative could lead to a delay in care. The facility's policy required the DON or a designee to obtain documentation designating the representative, but this was not done for Resident 66.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident 6, who was identified as being at high risk for falls. Despite the care plan's directive to place floor mats on both sides of Resident 6's bed to minimize falls and injuries, observations on multiple occasions revealed that no floor mats were present. Resident 6, who had severe cognitive impairment and required maximum assistance with daily activities, was observed in bed without the necessary fall prevention measures in place. Interviews with staff, including Certified Nursing Assistants (CNAs) and the Director of Staff Development (DSD), confirmed the absence of floor mats and acknowledged the increased risk of falls and injury due to this oversight. The CNAs were either unsure or aware of the requirement for floor mats but could not explain their absence. The DSD confirmed that the care plan included floor mats as an intervention for residents with a history of falls, and the lack of implementation for Resident 6 was a deviation from the facility's policy and procedure for comprehensive person-centered care plans.
Failure to Update Fall Care Plan for Resident
Penalty
Summary
The facility failed to revise the fall care plan for a resident who sustained a fall on 10/27/2024. This resident, identified as Resident 6, was readmitted to the facility with diagnoses including cerebral infarction and dementia, which contributed to severe cognitive impairment and a high risk of falls. Despite the resident's history of falls and the recent incident, the care plan was not updated to reflect the change in condition, as confirmed by both the Licensed Vocational Nurse and the Director of Staff Development during interviews. The facility's policy requires that care plans be reviewed and updated when there is a significant change in a resident's condition. However, after the fall on 10/27/2024, no revisions were made to Resident 6's care plan, which was a deviation from the facility's established procedures. The lack of an updated care plan increased the risk of injury and recurrent falls for the resident, as the care plan did not address the most recent fall incident.
Failure to Implement Safety Interventions for Residents
Penalty
Summary
The nursing staff failed to provide necessary interventions to prevent accidents for two residents, Resident 6 and Resident 63, in the facility. Resident 6, who had a history of falls and was assessed as a high fall risk, was not provided with floor mats as indicated in their care plan. Observations on multiple occasions revealed that Resident 6's bed was in the lowest position, but no floor mats were present on either side of the bed. Interviews with the resident's representatives and CNAs confirmed the absence of floor mats, which were supposed to be in place to minimize the risk of injury from falls. Resident 63, who had a history of epilepsy and was diagnosed with hemiplegia and hemiparesis, was not provided with padded bedside rails as per the physician's orders. Observations showed that while the side rails were up, they lacked the necessary padding. Interviews with the treatment nurse and the DON confirmed that the padded side rails were required to prevent injury during seizures, yet they were not in place, posing a risk to the resident. The facility's policies and procedures for fall prevention and bed safety were not adhered to in these cases. The Fall Risk assessment and care plan for Resident 6 clearly indicated the need for floor mats, while the physician's orders and care plan for Resident 63 specified the use of padded side rails. The failure to implement these interventions as outlined in the residents' care plans and physician's orders resulted in a deficiency in ensuring a safe environment for these residents.
Missed Quarterly Nutritional Assessment for Resident
Penalty
Summary
The facility failed to perform a quarterly nutritional assessment for a resident, which had the potential to impact the resident's nutritional needs. The resident was admitted with multiple diagnoses, including Type II diabetes, dysphagia, hyperlipidemia, end-stage renal disease, and dependence on renal dialysis. The initial nutritional assessment indicated the resident was at risk for significant weight change due to these conditions and had expected weight fluctuations related to ESRD and hemodialysis. However, no further nutritional assessments were documented after the initial assessment. Interviews with the Registered Dietitian (RD), Dietary Supervisor (DS), and Director of Nursing (DON) confirmed that the resident's last nutritional assessment was conducted shortly after admission, and a subsequent quarterly assessment was missed. The facility's policy required nutritional assessments to be completed on admission, quarterly, annually, and as needed. The RD and DS acknowledged that the missed assessment could have led to potential weight loss and unmet nutritional needs for the resident.
Failure to Timely Change PICC Line Dressing
Penalty
Summary
The facility failed to adhere to its policy and professional standards of practice regarding the timely changing of a peripherally inserted central catheter (PICC) line dressing for a resident. Resident 49, who was admitted with a right middle finger fracture, cellulitis, and bacteremia, had a PICC line for administering Vancomycin to treat osteomyelitis. The dressing on the PICC line was observed to be dated nine days prior, exceeding the facility's policy of changing the dressing every seven days. During an interview, a registered nurse acknowledged that the dressing should have been changed two days earlier and was unsure why it had not been done. The Director of Nursing confirmed that the failure to change the dressing as required put the resident at risk for infection and other complications. The facility's policy mandates that dressings for central vascular access devices be changed at least every seven days, which was not followed in this instance.
Inadequate CNA Training on Fall Risk Identification
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) were competent in identifying residents who were at risk of falls, which compromised the safety of residents, including Resident 6. Two CNAs, CNA 1 and CNA 2, were unable to recognize the significance of a yellow star above Resident 6's bed, which indicated a high fall risk. CNA 1, who was new to the facility, did not know the meaning of the yellow star and had to ask another CNA for clarification. Similarly, CNA 2 was unaware of the star's meaning and stated that she had not been educated on it. This lack of knowledge among CNAs had the potential to place residents at risk for injury and recurrent falls. Resident 6, who had a history of falls and was identified as a high fall risk, was admitted with diagnoses including cerebral infarction and dementia, leading to severe cognitive impairment and a need for maximum assistance with daily activities. Despite the facility's policy requiring nursing staff to be knowledgeable about fall prevention, the Director of Staff Development (DSD) and the Director of Nursing (DON) acknowledged that safety and fall prevention had not been a focus of in-service training. The facility's policy indicated that competency requirements and training should be monitored by nursing leadership, but there was no evidence of in-service training on safety and fall prevention from July to October 2024, leaving a gap in staff education and competency monitoring.
Medication Availability and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the availability of divalproex extended release (ER) in the correct dose for a resident with epilepsy, leading to a potential risk of seizures. The resident was supposed to receive a total dose of 750 mg of divalproex ER every 12 hours, consisting of one 500 mg tablet and one 250 mg tablet. However, the Licensed Vocational Nurse (LVN) administering the medication was unaware that an additional 250 mg tablet was required, and the facility did not have the 250 mg tablets in stock. This oversight was confirmed through interviews with the LVN and the Director of Nursing (DON), who acknowledged the potential harm to the resident due to the incorrect dosage. Another resident was affected by the facility's failure to provide pyridoxine (vitamin B6) as prescribed. The resident, who had a diagnosis of Type II diabetes mellitus and unspecified anemia, was supposed to receive two 50 mg tablets of pyridoxine daily. However, during medication administration, it was observed that the pyridoxine was not in stock, and therefore, not administered. The DON confirmed the importance of having such vitamins in stock to prevent deficiencies. The facility's policy and procedure for administering medications require that medications be administered safely, timely, and as prescribed. The policy also mandates that the individual administering the medication verifies the right resident and dosage. Despite these guidelines, the facility failed to ensure the correct medications and dosages were available and administered, as evidenced by the lack of divalproex ER 250 mg and pyridoxine 50 mg in stock for the affected residents.
Failure to Limit PRN Lorazepam to 14 Days
Penalty
Summary
The facility failed to limit the as-needed medication, Lorazepam, to 14 days for a resident diagnosed with generalized anxiety disorder. The resident was admitted with moderately impaired cognition and was dependent on assistance for personal hygiene. A physician's order dated 10/10/2024 prescribed Lorazepam 0.25 mg via G-Tube every 8 hours as needed for anxiety, without specifying a stop date. This oversight was identified during a review of the resident's records, indicating non-compliance with the facility's policy on psychotropic medications. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the physician's order did not adhere to the facility's policy, which mandates a 14-day limit for PRN psychotropic medications unless a rationale for extension is documented. Both the RN and DON acknowledged the potential risk of the resident receiving excessive doses of Lorazepam, which could lead to adverse effects. The facility's policy, reviewed on 8/30/2024, clearly states that PRN orders for psychotropic medications should be limited to 14 days unless extended with documented justification.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration, resulting in a 12.9% error rate. This deficiency was observed in the cases of two residents. For Resident 4, the facility did not ensure the availability and administration of the correct dose of divalproex ER, a medication used to treat seizures. The resident was supposed to receive a total dose of 750 mg, consisting of one 500 mg tablet and one 250 mg tablet every 12 hours. However, the facility only administered the 500 mg tablet, as the 250 mg tablet was not available in stock. This oversight was due to a failure in ordering the correct medication from the pharmacy, as the facility only requested refills for the 500 mg tablet. In the case of Resident 63, the facility failed to administer metformin, a medication for diabetes, in a timely manner. The resident was supposed to receive metformin with breakfast, but due to uncertainty about whether the resident had eaten, the medication was not administered until later in the morning. Additionally, the facility did not have pyridoxine, a vitamin B6 supplement, in stock, and administered an incorrect dose of cranberry, a supplement for UTI prevention. These errors were attributed to a lack of proper medication stock management and verification of medication doses before administration. The facility's policy and procedure for administering medications require that medications be administered safely, timely, and as prescribed. However, the facility staff failed to adhere to these guidelines, resulting in medication errors that placed the residents at risk for medical complications. The Director of Nursing acknowledged the potential harm to the residents due to these errors, emphasizing the importance of ensuring correct medication doses and timely administration to prevent adverse health outcomes.
Failure to Update and Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor and update the food preferences of a resident, leading to decreased meal satisfaction and overall caloric intake. The resident, who was readmitted with multiple diagnoses including acute embolism, Guillain-Barre Syndrome, and spinal stenosis, had specific food preferences documented in their care plan and dietary profile. However, these preferences were not consistently updated or honored. The resident's care plan indicated a preference for juice and milk for breakfast and a dislike for certain foods like tuna and chicken breast. Despite this, the resident received meals that did not align with their preferences, as observed during an interview where the resident expressed dissatisfaction with the food provided. The dietary profile for the resident was found to be incomplete and missing crucial information about their likes and dislikes. The Dietary Supervisor acknowledged that the resident's preferences were accidentally removed during a menu update and were not aware of the oversight. The facility's policy required the identification of food preferences upon admission or within 24 hours, but this was not adhered to in the resident's case. The lack of documentation and failure to update the dietary profile led to the resident receiving meals that did not meet their preferences, causing frustration and dissatisfaction.
Lack of Contract and Orientation for Cosmetologist
Penalty
Summary
The facility failed to establish a contract with a cosmetologist who provided services to residents, including Resident 47, for two years. The cosmetologist was not employed by the facility and did not receive an orientation program as required by the facility's policy. During an observation, the cosmetologist entered Resident 47's room without knocking or ensuring privacy, which raised concerns about adherence to professional standards of practice. Interviews with facility staff, including the Administrator, Director of Staff Development, and Social Services Director, revealed that there was no contract or vendor file for the cosmetologist, and it was unclear if the cosmetologist held a valid license. Resident 47, who was admitted with Alzheimer's disease and dementia, was observed receiving a haircut from the cosmetologist without any documented request from the family or facility for such services. The facility's policy required all vendors to have a contract and undergo a 10-hour orientation program, which the cosmetologist did not complete. The lack of a contract and orientation program for the cosmetologist posed an increased risk of services not being in accordance with professional standards, as noted by the Director of Nursing.
Inadequate Respirator Fit Testing for Staff
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically regarding the mandatory respirator fit testing for staff members. During observations and interviews, it was noted that several staff members, including Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs), were wearing Medline NON24506A Regular TC 64A5411 NIOSH N95 respirators without having been properly fit-tested for this specific model. This was confirmed through interviews with the staff and a review of their fit test records, which indicated that they had not been fit-tested for the respirators currently in use. The Infection Preventionist (IP) acknowledged that the staff had not been fit-tested for the Medline model N95 respirators, which were introduced during a COVID-19 outbreak in the facility. The facility's policy requires fit tests to be conducted annually or when there is a change in the respirator model. The lack of fit testing could result in improper sealing of the respirators, potentially exposing residents and staff to airborne infectious diseases. The facility was in the process of updating the fit testing for the employees, as confirmed by the Administrator.
Failure to Offer Vaccines to Cognitively Intact Resident
Penalty
Summary
The facility failed to offer influenza, pneumonia, and COVID-19 vaccines to a resident who was cognitively intact and capable of making her own medical decisions. The resident was admitted with several respiratory-related diagnoses, including acute respiratory failure, pulmonary emphysema, congestive heart failure, and COPD, and was dependent on supplemental oxygen. Despite being self-responsible, the facility sought consent from the resident's family member, who refused the vaccines on her behalf. The Minimum Data Set indicated that the resident was cognitively intact, and the facility's Infection Preventionist and Director of Nursing confirmed that the resident was capable of making her own decisions. However, the consent forms for the vaccines showed that the family member refused them, and the resident herself was not offered the vaccines. The resident expressed her desire to receive the vaccines and was unaware of why her family was consulted instead of her. The facility's policies required that all residents be offered the influenza and pneumococcal vaccines unless medically contraindicated. The Infection Preventionist acknowledged that the resident should have been asked directly about her vaccination preferences. The failure to offer the vaccines to the resident, who had not received a pneumonia vaccine previously, placed her at increased risk of acquiring these infections.
Resident Safety Compromised Due to Inadequate Monitoring
Penalty
Summary
The facility failed to ensure the safety and well-being of a resident when another resident entered their room uninvited during the night and kissed them on the cheek. This incident involved a resident with intact cognition and memory, who was unable to ambulate and required maximum assistance with activities of daily living. The resident reported feeling nervous and violated after the encounter. The other resident involved had moderate cognitive impairment due to dementia, was independent in using a wheelchair, and had a history of impaired decision-making and short-term memory loss. The incident occurred when the resident with dementia, who was known to be social and used a wheelchair to move around the unit, entered the other resident's room at night. Despite the resident's room being located near the nursing station, no staff observed the resident leaving their room or entering the other resident's room. The facility's policy on abuse and neglect defines sexual abuse as non-consensual sexual contact, which was applicable in this situation. Interviews with staff indicated that increased monitoring could have potentially prevented the incident, but no specific reason was provided for the lack of staff intervention at the time of the incident.
Inadequate Supervision of Dementia Resident Leads to Wandering Incident
Penalty
Summary
The facility failed to implement individualized interventions for a resident diagnosed with dementia, resulting in an incident where the resident wandered into another resident's room and kissed them on the cheek. The resident, who had moderate cognitive impairment and was independent in using a wheelchair, was not adequately supervised despite having a care plan that included redirection and communication with family. The care plan lacked specific interventions for supervision, which contributed to the incident. Interviews with staff revealed that the resident was known to have episodes of confusion and was supposed to be closely monitored for wandering. However, the Charge Nurse and Director of Staff Development acknowledged that the resident was not adequately supervised, as evidenced by the incident occurring without staff intervention. The Director of Nursing noted that the resident's room was near the nursing station, yet no staff witnessed the resident leaving their room, indicating a lapse in supervision. The facility's policy required direct care staff to supervise residents with dementia, but this was not effectively implemented in this case.
Failure to Maintain Clean and Sanitary Fall Mats
Penalty
Summary
The facility failed to maintain clean and sanitary fall mats in two out of four sampled residents' rooms, which could potentially expose residents to germs and spread infection. Resident 2, who was admitted with multiple diagnoses including metabolic encephalopathy, anemia, type two diabetes mellitus, paraplegia, and dysphagia, was observed to have soiled fall mats with shoe marks and dust on the floor beside their bed. Resident 2, who had severe memory problems and was dependent on staff for various activities, stated they had not seen anyone clean the fall mats. Similarly, Resident 1, who was cognitively intact but dependent on staff for daily activities, also had fall mats with dust, dark spots, and dirty footwear marks. Resident 1 reported that housekeeping mopped the floor around the mats but did not clean the mats themselves. Resident 3, who shared a room with Resident 2, confirmed that while the floor was cleaned daily, the fall mats were not. A review of the facility's maintenance logbook did not show any record of cleaning the fall mats, nor did it indicate a process for doing so. The facility's policy on cleaning and disinfection of environmental surfaces, dated August 2019, stated that surfaces should be cleaned regularly and when visibly soiled, but this was not adhered to in the case of the fall mats. This oversight in maintaining a clean environment for the residents was identified through observation, interviews, and record reviews.
Infection Preventionist Certification Records Unavailable
Penalty
Summary
The facility failed to ensure that their acting Infection Preventionist (IP) had accessible and available certification or training records in infection prevention and control. During a review of the Director of Staff Development's (DSD) employee file, no IP certificate or training records were found. The DSD, who was acting as the IP, claimed to have an Infection Preventionist certificate but was unable to provide a copy for review. This lack of documentation was identified during an interview with the DSD. The facility's job description for the Infection Preventionist role indicated a requirement for specialty training in Infection Prevention and Control through accredited continuing education. Additionally, the facility's policies and procedures stated that all personnel would be trained on infection control policies and practices upon hire and periodically thereafter. According to the All Facilities Letter issued by the California Department of Public Health, the IP must be qualified by education, training, clinical or healthcare experience, or certification, and must have completed specialized training in infection prevention and control. The absence of accessible training records for the acting IP posed a potential risk for the facility's infection prevention and control program not being maintained, thereby placing residents and staff at risk for healthcare-associated infections.
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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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