The Gardens Of El Monte
Inspection history, citations, penalties and survey trends for this long-term care facility in El Monte, California.
- Location
- 5044 Buffington Rd, El Monte, California 91732
- CMS Provider Number
- 555903
- Inspections on file
- 44
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at The Gardens Of El Monte during CMS and state inspections, most recent first.
Failure to maintain resident privacy and dignity during care and medication pass: an LVN exposed one resident’s abdomen to roommates while assessing a GT site and during medication administration, and left another resident visible to the hallway with the curtain not pulled and the door open. Both residents had significant cognitive impairment and were dependent on staff for multiple ADLs; the LVN stated the curtains were forgotten, and the DON stated staff should close curtains for privacy and dignity during care.
Failure to Document Hospital Transfer Reports: Two residents were transferred to a GACH, but their charts did not contain transfer report documentation. One resident had a change in condition with pain, weakness, lethargy, and a fall-related transfer order; the other had poor intake, swallowing difficulty, and a transfer order to the hospital. Nursing notes showed both residents left the facility, but the records lacked the required transfer packet, report details, and related documentation referenced by the DON and facility policy.
A resident admitted with metabolic encephalopathy and dementia had an ADAF that was conflicting, as it indicated both that the resident had executed an AD and that the resident had not executed an AD. RN, SSD, and DON interviews confirmed staff could not determine whether the resident had an AD because the form was not clear or accurate.
Failure to Code Bilateral Wedge Cushions as a Restraint: A resident with dementia, bipolar disorder, and depression had bilateral bolster wedge cushions applied in bed, with a physician order, care plan, and RP consent describing the device as an enabler/restraint. The MDS consultant, MDS nurse, RN, LVNs, and DON stated the cushions should have been coded as a restraint on the MDS, but they were not, and staff said the resident used the wedges because of poor safety awareness, unsafe self-positioning, and attempts to wiggle out of bed.
Failure to revise a fall care plan after a resident had an unwitnessed fall. The resident had pneumonia, acute and chronic respiratory failure with hypoxia, and gait and mobility abnormalities, with intact cognition and need for supervision or touch assist for transfers and ambulation. LVN 4 stated the resident had a fall and was monitored more, and that the resident used a wheelchair to ambulate, but the At Risk for Falls and Actual Fall care plans were not revised. The DON confirmed the care plans should have been revised, and the facility policy required ongoing review and revision of the CP.
Incomplete Daily Nurse Staffing Posting: The facility failed to complete and post the NHPPD at the start of each shift. Observation showed the staffing board was not updated and did not include the current date or the actual hours worked by licensed and unlicensed nursing staff. The DSD and Payroll Staff stated the form was not completed on time and that the posted documents only showed projected hours, while the DON stated the posting should be completed early in the morning and used to verify staff presence and resident care hours.
Medication Found on Hallway Floor: A small, round, white pill was observed on the hallway floor across from Nursing Station 1 while staff and residents were passing through the area. The RN supervisor stated a resident could have picked it up and eaten it, and the DON stated medication should not be on the floor because the nurse should ensure it is taken by the resident. Facility policy stated medications and biologicals were to be stored safely and in locked areas.
A resident’s elopement risk CP was inaccurately dated, with the DON confirming the date entered on the CP update was incorrect and should have matched the resident’s elopement date. The resident had diagnoses including metabolic encephalopathy, bipolar disorder, and depression, and the H&P noted fluctuating capacity to understand and make decisions. The facility’s documentation policy required records to be current and entries to be accurate and timely.
Failure to monitor a high-risk elopement resident led to an elopement from the facility. The resident had metabolic encephalopathy, bipolar disorder, depression, fluctuating decision-making capacity, and a high elopement/wander risk score with a history of a 5150 hold and wanting to go home. The care plan called for frequent monitoring, but the DON stated the behavior monitoring form was not consistently given to staff, monitoring was not continuously or regularly done, and whereabouts were not consistently documented. The resident was later found to have used the back exit area and was returned by police after about an hour.
Resident rooms 2, 8, 10, 11, 15, and 16 did not meet the required minimum square footage for multiple-occupancy rooms. Surveyors observed that residents could still move freely and staff had space to provide care with dignity and privacy, and the ADM stated the facility had submitted a room-size waiver. Residents interviewed did not express concerns about the room sizes.
A resident with dementia and schizophrenia, who had severely impaired cognition and required assistance with some ADLs, had a physician’s order for Depakote three times daily for angry outbursts. Over several days, an LVN did not administer multiple scheduled doses because the medication was not in the cart and was awaiting pharmacy delivery. Another LVN stated the nurse should have contacted the pharmacy and used the emergency kit, and the DON confirmed Depakote was part of the resident’s psychotropic regimen and should have been given as ordered. Review of the MAR and facility policies showed that required steps to obtain and administer the medication in a timely manner, including use of the emergency kit, were not followed, resulting in multiple missed doses.
Two residents with mild cognitive impairment and multiple diagnoses were moved to different rooms without receiving the required written notice or providing consent. Facility staff confirmed that written Notices of Room Change were not given and signatures were not obtained prior to the moves, in violation of facility policy and resident rights.
Three residents were discharged without proper physician orders, documentation of discharge reasons, or signed Notices of Transfer/Discharge. In one case, a resident was sent to a facility at the same level of care against their stated goal; in another, a resident was discharged without a documented reason or consent; and a third resident, who required assistance with ADLs, was discharged to an independent living home not suited to their needs. Staff interviews confirmed that required procedures and documentation were not followed.
The facility failed to properly document and communicate required information on transfer/discharge notices for three residents, including not specifying the correct reason for transfer, omitting the transfer location, and not providing the notice prior to discharge. These deficiencies involved residents with complex medical and cognitive needs and were confirmed by interviews and record reviews.
A resident with depression, anxiety, and schizophrenia was moved to a new room without the development or implementation of a care plan to monitor psychosocial well-being and adjustment. Nursing staff and leadership confirmed that no such care plan was created, despite facility policy requiring comprehensive, resident-centered care plans following significant changes.
A resident with mental health and mobility diagnoses requested assistance from staff to obtain a state ID card, but the facility did not assign anyone to help with the application process. Staff interviews confirmed the request was made and not fulfilled, despite facility policy requiring social services to assist with obtaining personal identification.
A resident with impaired mobility and cognition was repeatedly kept in a reclining wheelchair and physically prevented from standing by staff, who cited fall risk and convenience as reasons. Staff interviews and facility policy reviews confirmed that the resident's freedom of movement was restricted without proper assessment or consent, constituting a violation of resident rights and use of a physical restraint.
A resident with severe cognitive impairment and mobility issues was found to have been tied to a wheelchair with a sheet, restricting movement, without a physician order. Staff and another resident confirmed that this practice occurred, despite facility policy prohibiting physical restraints for staff convenience or discipline.
A resident with anxiety disorder and impaired cognition did not have a care plan for mental health services or increased socialization, despite psychiatric recommendations and observed withdrawn behavior. The resident was often alone, expressed sadness and boredom, and staff did not engage with the resident, contrary to facility policy on resident rights.
A resident with severe cognitive impairment and a high risk for falls experienced multiple falls resulting in injuries, while the facility failed to update or revise the fall risk care plan as required. Despite recommendations for increased supervision and evidence of repeated falls, the care plan remained unchanged, and staff did not consistently provide the necessary supervision during ambulation.
During an electrical fire in the main panel room, staff failed to activate the manual fire alarm as required by facility policy. Instead, staff called 911 and notified others verbally, but did not use the nearest manual pull station, resulting in the fire alarm not being triggered and the facility not being fully alerted.
Surveyors found that the facility did not have documentation showing its emergency generator had undergone a required four-hour continuous load test within the past 36 months. Administrative and maintenance staff were unable to provide evidence of compliance, and the only available service report showed a test duration of just over three hours, not meeting regulatory standards.
The facility failed to follow its Advance Directive policy for two residents. One resident did not have the Advance Directive Acknowledgement Form completed upon admission, while another had an incomplete form, despite having severely impaired cognition. This oversight could lead to treatment against the residents' wishes.
A resident with COPD and Diabetes Mellitus experienced a sudden change of condition, including heavy breathing and a change in face color. The RN failed to assess vital signs or notify the physician, contrary to facility policy. This oversight potentially delayed necessary treatments, contributing to the resident's health decline.
The facility failed to manage oxygen therapy properly for four residents, leading to deficiencies in care. A resident did not receive continuous oxygen as ordered, another had unlabeled tubing, a third had improperly placed nasal cannula, and a fourth received oxygen without a physician's order. These issues were confirmed by staff and the DON, highlighting lapses in adherence to professional standards and facility policies.
A facility failed to monitor a physician-ordered fluid restriction for a resident on dialysis, risking fluid imbalance. The resident, with conditions including diabetes and end-stage renal disease, had a fluid restriction order of 1000 ml per day, which was not documented in the MAR for two weeks. Interviews with the DSD and DON confirmed the oversight, acknowledging potential complications from unmonitored fluid intake.
A facility failed to administer Losartan as ordered, as a nurse did not check a resident's BP before administration, despite a previous reading below the threshold. Additionally, medication destruction was not witnessed by two licensed nurses as required, risking medication misappropriation.
The facility failed to ensure that kitchen staff adhered to its policy on wearing hairnets during food preparation. Kitchen Aide 1 was observed without a hairnet while handling meal trays, acknowledging the oversight and its potential to contaminate food. The Dietary Supervisor confirmed the requirement for hairnets to prevent contamination, as outlined in the facility's policy.
A resident with paraplegia and severely impaired cognition was found unable to reach their call light, contrary to the facility's policy. The call light was observed hanging out of reach, confirmed by both the resident and an LVN. The DON stated that call lights should be within reach to ensure safety and prevent falls.
A facility failed to accurately code a resident's MDS, indicating discharge to a hospital instead of home with home health care. The resident had conditions including cellulitis, seizures, and anemia. Interviews with the MDS Coordinator and DON confirmed the error, highlighting the importance of accurate coding for continuity of care and CMS reporting.
A resident with severe cognitive impairment and dependency on staff for care was involved in a medication administration error. A nurse documented medications as given in the EMAR before they were actually administered due to an issue with the resident's gastrostomy tube. This action was against the facility's policy, which requires documentation only after administration to prevent errors.
A resident with a gastrostomy tube did not receive prescribed enteral feeding due to an unlabeled feeding bottle and an enteral pump machine that was turned off. The resident's order required continuous administration of Glucerna 1.2 formula, but the Licensed Vocational Nurse delayed turning on the machine, risking dehydration and electrolyte imbalance. The facility's policy required proper labeling and documentation to prevent errors, which was not followed.
The facility failed to document medication administration and blood glucose monitoring for two residents, leading to potential medication errors. One resident's MAR did not show Hydralazine administration or blood glucose monitoring, while another resident's MAR lacked documentation of blood glucose monitoring. Staff interviews highlighted the importance of immediate documentation to prevent errors.
The facility did not meet the square footage requirements for six resident rooms, with Rooms 2, 8, 10, 11, 15, and 16 falling short of the required space per resident. Despite this, residents were able to move freely, and staff could provide care with dignity and privacy. A room waiver request was submitted, indicating no jeopardy to resident health and safety.
A resident with dementia and other health conditions fell in the facility, but the responsible party was not informed. The LVN did not leave a detailed voicemail, and the facility lacked a policy for notifying responsible parties about falls. The DON confirmed the requirement to notify families, highlighting a communication lapse.
A resident at risk for skin breakdown and pressure injuries did not receive daily skin assessments as required. Despite having existing skin conditions, these were not documented in the admission assessment or daily notes. Staff relied on outdated information, failing to conduct physical assessments, which led to inaccurate documentation and potential lack of treatment for skin issues.
A resident's medical record was found to be incomplete and inaccurate due to the failure to document a laceration and discoloration on the resident's face. The ADON and TN acknowledged the omission, and RN 1 admitted to copying previous assessments without conducting a physical examination. The facility's policy requires accurate and timely documentation, which was not followed.
A facility failed to document follow-up actions for a resident's video swallow study, despite the resident having conditions like parkinsonism and dysphagia. The DON acknowledged the importance of documenting follow-up to prevent complications, but the ADON's inquiry about the test results was not recorded, violating the facility's policy for maintaining detailed clinical records.
A resident with a history of dysphagia and chronic kidney disease did not receive adequate hydration, leading to severe health issues. Despite the care plan indicating a risk for dehydration, the resident's fluid intake was consistently below the required amount. Facility staff failed to monitor and report the resident's fluid intake, resulting in the resident being hospitalized with hypernatremia, dehydration, uremia, and acute kidney injury.
A resident with a history of dysphagia and chronic kidney disease experienced inadequate fluid intake, leading to hypernatremia and hospitalization. The facility failed to notify the physician of the resident's change in condition and did not obtain necessary orders to monitor fluid intake and output. Staff interviews revealed a lack of communication and awareness regarding the resident's fluid needs, resulting in delayed care.
A resident with multiple medical conditions was unsafely discharged 497 miles away from the facility with nowhere to stay. Despite the family member's clear refusal to take the resident home, the facility proceeded with the discharge, resulting in the resident being left at the Social Services department and later in a motel without proper accommodation.
The facility failed to implement an effective pest control program, resulting in the presence of fruit flies in a resident's room and the conference room. Observations and interviews revealed that the facility's doors needed to be kept closed to prevent pests and that the pest control company should be called when fruit flies are present.
The facility failed to provide reasonable accommodation for two residents. One resident's call light was not within reach, and another resident's clock was not adjusted after Daylight Saving Time, causing confusion. Staff acknowledged these issues, which were against the facility's policies.
The facility failed to follow its Advance Directive policy for two residents. One resident was not provided with AD information upon readmission, and another resident's AD was not retrievable in the medical records despite having severely impaired cognition and total dependence on staff.
A resident with dementia and chronic kidney disease was found with unexplained injuries, including bruises and a bump on the forehead. The facility staff failed to report the injuries within the required two-hour timeframe, did not investigate the injuries according to policy, and did not notify the resident's physician or responsible party. These actions compromised the resident's safety and protection from potential abuse.
The facility failed to ensure safe and appropriate respiratory care for two residents receiving oxygen therapy. The nasal cannula tubing for both residents was observed touching the floor, and there were no cautionary signs posted on their doors indicating oxygen was in use or that smoking was prohibited. Both residents had severe cognitive impairments and were totally dependent on staff for daily activities. The facility's policies on oxygen administration and storage of oxygen cylinders were not followed.
The facility failed to use the services of an RN for at least eight consecutive hours a day, seven days a week for 12 of 15 days. The Director of Staff Development confirmed that the facility had no full-time RN working eight hours per day, seven days a week since February 2024. The facility's policy indicated that RN staff should be available to provide and monitor the delivery of resident care services.
The facility failed to ensure the sanitizing solution used for cleaning the food preparation area met the required concentration of 200 ppm, potentially leading to contamination and foodborne illness. One of the three red buckets had a concentration of only 100 ppm, as confirmed by the Dietary Assistant and Supervisor.
The facility failed to ensure that the call light was within reach for a resident with severe cognitive impairment and mobility issues, despite the care plan and facility policy requiring it. This was confirmed through observation and staff interviews.
The facility failed to obtain an informed decision from a resident's representative regarding payment for non-covered services after the resident was discharged from Medicare Part A. The Business Office Manager issued the required notices but did not follow up to ensure the representative was informed about financial responsibilities, and mistakenly checked an incorrect option on the form.
Failure to Maintain Resident Privacy and Dignity During Care
Penalty
Summary
The facility failed to promote and treat two residents with respect, privacy, and dignity during care and medication administration. Resident 9 was admitted with diagnoses including a gastrostomy and Parkinson’s disease without dyskinesia, and the MDS indicated severely impaired cognition and dependence on staff for oral hygiene, toileting, lower body dressing, footwear, and personal hygiene. During an observation in Resident 9’s room, an LVN lifted the resident’s gown and assessed the gastrostomy tube site without pulling and closing the privacy curtain, exposing the resident’s abdominal area to two roommates. During a later medication pass in the same room, the LVN again did not fully close the privacy curtain, leaving the resident’s abdomen exposed to the two roommates present. Resident 37 was admitted with diagnoses including metabolic encephalopathy and dementia with other behavioral disturbances, and the MDS indicated the resident was rarely or never understood and dependent on staff for oral hygiene, toileting, lower body dressing, footwear, and personal hygiene. During an observation, the LVN did not pull the privacy curtain and left Resident 37’s door open during the medication pass, exposing the resident to anyone passing in the hallway. When interviewed, the LVN stated the privacy curtains were forgotten for Residents 9 and 37 and should have been closed for privacy reasons to respect the residents’ dignity during procedures. The DON stated nursing staff should pull the curtain closed for resident privacy and dignity during any care given to a resident.
Failure to Document Hospital Transfer Reports
Penalty
Summary
The facility failed to document transfer reports in the medical records for two residents who were sent to a General Acute Care Hospital. Resident 6 had diagnoses including encephalopathy, spondylolisthesis, low back pain, and polyneuropathy, and the History and Physical indicated the resident had the capacity to understand and make decisions. After a change in condition with generalized pain, weakness, back pain, and lethargy, a physician ordered transfer to the hospital for increased generalized weakness, lower back pain, and status post fall. Nursing notes documented that Resident 6 was transferred, and the Ombudsman transfer/discharge notice stated the transfer was necessary for the resident’s welfare and that the resident’s needs could not be met in the facility. During record review, there was no documented evidence that staff provided a transfer report to the hospital for Resident 6’s transfer. An LVN stated that when a resident is transferred to the hospital, nursing staff should call the hospital, give an endorsement report, and document that information in the resident’s chart. The DON stated the Charge Nurse or Supervisor was responsible for documenting the resident’s transfer information, including the actual report given to the hospital and to whom it was given. The facility policy titled Discharging the Resident stated that when a resident is discharged to a hospital or another facility, a transfer summary should be completed and a telephone report made to the receiving facility. Resident 8 had diagnoses including a gastrostomy and dementia, and the History and Physical noted the resident had recently been hospitalized for poor oral intake. A physician ordered transfer to a hospital for poor intake and inability to swallow food/pocketing, and nursing notes documented that the resident was transferred out of the facility by ambulance. However, the medical record did not contain transfer report documents for the transfer. The LVN stated the transfer packet should have shown the resident left the facility, the destination, the reason for transfer, proof of notifications, and the resident’s skin assessment. The DON stated the nursing staff needed to document the actual report given to the hospital and maintain a copy in the resident’s chart, and the facility policy required a transfer summary and telephone report to the receiving facility, with documentation of the resident’s condition at discharge including skin assessment if the medical condition allowed.
Conflicting Advance Directive Acknowledgment Form
Penalty
Summary
The facility failed to ensure its Advance Directive policy and procedure was implemented for one sampled resident. Resident 37 was admitted with diagnoses including metabolic encephalopathy and dementia with other behavioral disturbance. The resident's MDS dated 3/12/2026 indicated the resident was rarely or never understood and was dependent on staff for oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and personal hygiene. During record review and interviews with the RN Supervisor, SSD, and DON, Resident 37's Advance Directive Acknowledgment Form dated 7/30/2025 was found to be conflicting because it indicated both that the resident had executed an AD and that the resident had not executed an AD. The RN Supervisor stated staff would not know whether the resident had an AD, the SSD stated the form needed to be clarified and accurate, and the DON stated that when both statements were checked staff were unable to determine whether the resident had an AD.
Failure to Code Bilateral Wedge Cushions as a Restraint
Penalty
Summary
The facility failed to accurately assess Resident 3 by not coding bilateral bolster wedge cushions as a restraint on the Minimum Data Set dated 2/26/2026. Resident 3 was admitted with diagnoses including dementia, bipolar disorder, and depression, and the H&P dated 1/13/2026 stated the resident did not have the capacity to understand and make decisions. The MDS also showed severely impaired cognition and dependence on staff for eating, oral and toileting hygiene, showers, and upper and lower body dressing. Resident 3’s order summary dated 1/12/2026 directed staff to apply bilateral bolster wedge cushions in bed as an enabler to help the resident identify the edge of the bed due to poor safety awareness and unsafe self-positioning. An undated informed consent signed by the responsible party described the bilateral booster wedge cushion in bed as an enabler for the same purpose. During observation on 4/7/2026, Resident 3 was resting in bed with bilateral pillow wedges placed on each side. During interviews, the MDS consultant, MDS nurse, RN, LVNs, and DON stated the bilateral bolster wedge cushions were considered a restraint and should have been coded as such in the MDS because there was a physician’s order, care plan, and signed restraint consent. Staff also stated the cushions were used because Resident 3 would wiggle out of bed and try to get out of bed, and that the restraint information was not being communicated in the MDS. The facility policy stated the RAI process is used for accurate assessment of each resident’s functional capacity and health status, and the restraint policy defined a restraint as a device that restricts freedom of movement or normal access to one’s body when the resident cannot mentally or physically self-release.
Failure to Revise Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for fall risk for one resident after the resident had an unwitnessed fall. The resident was admitted and later readmitted with diagnoses including pneumonia, acute and chronic respiratory failure with hypoxia, and abnormalities of gait and mobility. The resident's H&P indicated the resident had the capacity to understand and make decisions, and the MDS dated 2/27/2026 indicated intact cognition and that the resident required supervision or touch assistance with sit-to-stand and walking 10 to 50 feet with two turns. A review of the resident's SBAR dated 1/23/2026 showed an unwitnessed fall. During interview and record review, LVN 4 stated the resident had a fall and the interventions included more monitoring, and also stated the resident used the resident's wheelchair to ambulate. Review of the At Risk for Falls care plan dated 12/30/2025 and the Actual Fall care plans dated 1/22/2026 and 1/23/2026 showed no revisions. The DON stated the care plans were not revised and should have been revised, and the facility's policy required care plans to be reviewed and revised periodically and on an ongoing basis to reflect changes in the resident and services provided.
Incomplete Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to follow its policy to complete and post the nurse staffing information at the start of each shift. On 4/7/26, during observation at the entrance notice board across from nurse's station 1, the Census and Direct Care Service Hours Per Patient Day (NHPPD) postings for 4/6/26 and 4/7/26 were not updated or completed. The posted documents did not show the total number of projected hours and the actual hours of licensed and unlicensed nursing staff directly responsible for resident care per shift. During interviews and record review, the DSD stated that the NHPPD for 4/6/26 and 4/7/26 was not completed and that the DSD was responsible for completing the staffing information, although it was being submitted by Payroll Staff. The DSD stated the form was supposed to be completed and posted in the morning before 8:00 AM and had to be completed daily. Payroll Staff stated the NHPPD would be completed the next day around 12:00 PM and that the posted documents for 4/6/26 and 4/7/26 were incomplete because they only showed projected hours and not actual hours. The DON stated the NHPPD should be completed and posted early in the morning at the beginning of the day shift, and that it served as a record to verify that the staff listed as working were actually present and provided resident care daily and for every shift.
Medication Found on Hallway Floor
Penalty
Summary
The facility failed to ensure safe provision of pharmaceutical services when a small, round, white pill was found lying on the hallway floor across from Nursing Station 1. During the observation, two nurses were in Nursing Station 1, and other staff and residents were walking through the hall. The pill was observed on the floor during a concurrent observation and interview with the RN supervisor, who stated there should not have been a pill on the floor and that a resident could have picked it up and eaten it. The RN supervisor also stated the medication was unknown and would be properly disposed of. During interview, the DON stated there should not be any medication on the floor because the nurse should ensure the medication was taken by the resident. The DON stated there were confused residents in the facility and one of them could have taken the pill without staff knowing what was affecting the resident. Review of the facility’s Medication Storage in the Facility policy stated medications and biologicals were to be stored safely, securely, and properly and accessible only to authorized personnel, and the Facility Guidelines stated medications were to be stored in locked areas.
Inaccurate Dating of Elopement Risk Care Plan
Penalty
Summary
The facility failed to accurately date Resident 16’s Care Plan for elopement risk. Resident 16 was admitted with diagnoses including metabolic encephalopathy, bipolar disorder, and depression, and the admission H&P noted fluctuating capacity to understand and make decisions. The MDS indicated intact cognition and partial/moderate assistance needed to walk 10 feet. During interview and record review, the DON reviewed Resident 16’s Elopement Risk Care Plan and stated the date entered as 3/6/2026 was incorrect and should have been 4/6/2026, the date of the resident’s elopement. The facility’s Documentation Principles policy required clinical records to be current and entries to be accurate, timely, objective, specific, concise, legible, clear, and descriptive.
Failure to Monitor High-Risk Elopement Behavior
Penalty
Summary
The facility failed to monitor behavior for a resident identified as high risk for elopement, and the resident eloped from the facility. The resident was admitted with metabolic encephalopathy, bipolar disorder, and depression, and the H&P noted fluctuating capacity to understand and make decisions. The MDS indicated intact cognition, neurological conditions, and partial/moderate assistance needed to walk 10 feet. The elopement/wander risk assessment dated 3/5/26 showed a score above 10, indicating high elopement risk, with a history of a 5150 hold, verbalizing wanting to go home, and a need for close monitoring. The resident’s elopement risk care plan also identified a score above 10 and called for frequent staff monitoring of whereabouts, but the care plan did not specify the frequency. During interview, the DON stated frequent monitoring meant every hour, but also stated the behavior monitoring form used to document this was not consistently provided to staff and that monitoring of elopement and behavior was not continuously or regularly done because the form was not available. The DON stated there was not consistent documentation of the resident’s whereabouts and that monitoring for increased wandering and exit-seeking behaviors was not being monitored and documented. During observation, an outside gate was noted, and the DON stated the back exit door was thought to have been used for the elopement; the resident was gone for about one hour and was returned by police.
Resident Rooms Did Not Meet Minimum Square Footage Requirements
Penalty
Summary
The facility failed to ensure six of 23 resident rooms—Rooms 2, 8, 10, 11, 15, and 16—met the required minimum of 80 square feet per resident in multiple resident rooms. During observation of the facility, surveyors noted that these rooms did not meet the square footage requirement, although the residents in the rooms were able to ambulate freely and/or maneuver in their wheelchairs freely. Nursing staff had enough space to provide care with dignity and privacy, and there was space for beds, side tables, dressers, and other medical equipment. During interview, the Administrator stated the facility had submitted a room size requirement waiver for Rooms 2, 8, 10, 11, 15, and 16. Review of the waiver request letter dated 4/9/2026 showed the facility stated there was enough space for nursing care and that the health and safety of the residents occupying these rooms were not in jeopardy. The letter also stated the rooms were in accordance with the needs of the residents and would not adversely affect their health and safety or impede their ability to attain their highest practicable well-being. The report included room measurements showing the square footage for these rooms, and residents interviewed during the recertification survey did not express concerns about the size of their rooms.
Failure to Administer Ordered Depakote Due to Lack of Medication Procurement
Penalty
Summary
The deficiency involves the facility’s failure to administer Depakote as ordered by the physician for a resident with dementia, schizophrenia, fluctuating decision-making capacity, and severely impaired cognition. The resident was originally admitted in early January and readmitted in March with orders on the Order Summary Report for Depakote three times daily for angry outbursts. The Minimum Data Set indicated the resident was independent with eating and hygiene but required moderate assistance with toileting, bathing, and transfers. Review of the March Medication Administration Record showed that Depakote was not administered at 9 AM and 1 PM on three consecutive days, and an additional 5 PM dose was missed on one of those days, resulting in seven missed doses out of eight ordered. During interviews, one LVN acknowledged not administering Depakote on multiple morning shifts because the medication was not available in the medication cart and was pending pharmacy delivery. Another LVN stated that it was important to administer Depakote for anger outbursts because it was part of the physician’s order and care plan, and that the nurse should have checked with the pharmacy and used the emergency kit while awaiting delivery. The DON confirmed that Depakote was part of the resident’s psychotropic medication regimen for behavioral management, stated the resident should have received the medication per the physician’s order and plan of care, and indicated it was not acceptable that the licensed nurse did not administer it. Facility policies on Medication Ordering and Receiving From Pharmacy and Medication Administration required timely receipt of medications, use of the emergency kit when needed before delivery, and administration of medications in accordance with physician orders within one hour before or after the prescribed time.
Failure to Provide Written Notice Before Room Changes
Penalty
Summary
The facility failed to provide written notice to two residents prior to changing their rooms, as required by policy and resident rights regulations. One resident, who had diagnoses including depression, anxiety disorder, abnormalities of gait and mobility, and schizophrenia, was assessed as mildly impaired in cognitive skills and required varying levels of assistance with daily activities. This resident reported not receiving any written notice before being moved to a different room and expressed not wanting the room change. Similarly, another resident with diagnoses of gait and mobility abnormalities, depression, anxiety disorder, hypertension, and schizophrenia, and who was also mildly cognitively impaired, stated that no written notice was given prior to their room change and did not consent to the move. Interviews with facility staff, including the Assistant Director of Nursing and the Social Service Director, confirmed that written Notices of Room Change (NORC) were not provided to the residents before the room changes occurred, nor were signatures obtained to verify receipt or consent. The facility's policy requires that residents receive written notice, including the reason for the change, before any room or roommate change is made. The lack of written notice and consent was acknowledged by both the nursing and social services staff during the investigation.
Failure to Ensure Safe and Orderly Resident Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly transfer or discharge for three residents by not following required procedures and documentation. For one resident with depression, anxiety disorder, and schizophrenia, the facility discharged the individual to another skilled nursing facility without a physician's order specifying the discharge location, without indicating the appropriate reason for discharge, and without providing or obtaining a signed Notice of Transfer/Discharge (NTD) from the resident. Interviews with staff confirmed that the NTD was not provided or signed prior to discharge, and the resident's discharge goal was to move to a lower-level care facility, not another skilled nursing facility. Another resident with chronic obstructive pulmonary disease, diabetes mellitus, and schizophrenia was discharged to a different skilled nursing facility without a documented reason for discharge and without a signed NTD. Staff interviews and record reviews confirmed that the required notice and consent were not obtained prior to the discharge, and the discharge reason was not clarified or documented on the NTD form. A third resident, who had hypertension, chronic kidney disease, dementia, and schizophrenia, and was severely impaired in cognitive skills, was discharged to an independent living home with home health services, despite requiring assistance with activities of daily living such as dressing and personal hygiene. Staff acknowledged that the discharge location was inappropriate given the resident's needs, and documentation confirmed the resident was not independent in ADLs at the time of discharge. Facility policies required notification, documentation, and preparation for discharge, but these were not followed in these cases.
Failure to Document Required Information on Transfer/Discharge Notices
Penalty
Summary
The facility failed to properly document and communicate required information on the Notice of Transfer/Discharge (NTD) forms for three residents. For one resident with depression, anxiety disorder, gait abnormalities, and schizophrenia, the NTD form incorrectly stated the reason for transfer as health improvement, despite the resident being transferred to another skilled nursing facility (SNF) of the same care level, contrary to the resident's discharge goal of moving to a lower-level care facility. The responsible staff did not provide the NTD form to the resident prior to discharge, and interviews confirmed that the discharge plan was not accurately reflected in the documentation. Another resident, diagnosed with COPD, diabetes mellitus, and schizophrenia, was transferred to a different SNF without any reason documented on the NTD form. The resident was cognitively intact and self-responsible, but both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged that the required reason for transfer was missing from the documentation. This omission was confirmed during interviews and record reviews. A third resident, with hypertension, chronic kidney disease, dementia, and schizophrenia, was transferred to an Independent Living Home (ILH), but the NTD form did not specify the location of the ILH. This resident was severely cognitively impaired and required significant assistance with daily activities. Facility policy requires that the reason for transfer/discharge and the location be clearly documented and communicated to the resident and/or their representative, but this was not done in these cases.
Failure to Develop Care Plan After Room Change
Penalty
Summary
The facility failed to develop and implement a person-centered care plan to monitor a resident's psychosocial well-being and satisfaction following a room change. The resident, who had diagnoses including depression, anxiety disorder, and schizophrenia, was admitted with mild cognitive impairment and required varying levels of assistance with daily activities. After the resident was moved to a new room, there was no care plan created to address the resident's adjustment or to monitor their psychosocial condition, as confirmed by review of the resident's records and interviews with nursing staff and facility leadership. Interviews with the LVN, ADON, and DON all confirmed that no care plan was developed after the room change, despite facility policy requiring comprehensive, resident-centered care plans that include measurable objectives and timeframes to meet each resident's needs. The absence of a care plan was also evident in the resident's current care plan documentation, which did not address the room change or the need to monitor the resident's psychosocial status following the move.
Failure to Provide Social Services for Resident ID Card
Penalty
Summary
The facility failed to provide medically-related social services to assist a resident in obtaining a legal personal identification (ID) card. The resident, who was admitted with diagnoses including depression, anxiety disorder, abnormalities of gait and mobility, and schizophrenia, was able to make needs known but could not make medical decisions. Assessment records indicated the resident was mildly impaired in cognitive skills and required varying levels of assistance with daily activities. Despite the resident's repeated requests for help in applying for a state ID card from the Department of Motor Vehicles (DMV) since admission, the facility did not provide the necessary assistance. Interviews with facility staff confirmed that the resident had asked for help obtaining an ID card, but no staff member was assigned to assist with the process. The Social Service Director acknowledged the request and the facility's responsibility to provide such assistance, while the Director of Staff Development confirmed that no arrangements were made for staff to accompany the resident to the DMV. Review of the facility's policy indicated that social services should include assistance with obtaining personal identification and other personal items, but this was not carried out for the resident in question.
Resident Restrained in Reclining Wheelchair, Denied Right to Stand
Penalty
Summary
A facility failed to ensure that a resident was treated with respect and dignity by not allowing the resident to get up from a reclining wheelchair, despite the resident's attempts to do so. The resident, who had a history of impaired mobility, unsteady gait, and severely impaired cognition, was observed multiple times throughout the day in a large reclining wheelchair with the chair tilted back and feet elevated. Staff interviews confirmed that the resident was kept in the chair for most of the day, with the chair often tilted back to prevent the resident from attempting to get up, as the resident was considered a fall risk. On one occasion, an Activities Assistant physically prevented the resident from getting up by placing hands on the resident's shoulder and instructing the resident to remain seated. The Activities Assistant stated that the chair was used to keep the resident from getting up due to fall risk and staff convenience, and that the chair was sometimes tilted back to make the resident more comfortable and discourage attempts to stand. A Certified Nurse Assistant confirmed that the resident required substantial assistance but was not completely dependent, and stated that if a resident wanted to get out of a reclining wheelchair, staff were supposed to assist them, as it was the resident's right. Further interviews with therapy staff indicated that using the wheelchair in this manner constituted a restraint, as it restricted the resident's freedom of movement and hindered quality of life. The facility's own policies defined restraints as any device that a resident cannot easily remove and that restricts movement, and stated that restraints should not be used for staff convenience. The Director of Nursing acknowledged that restricting residents from getting up when they wanted was a violation of resident rights, although there was confusion among staff regarding the definition and use of restraints.
Failure to Prevent Unnecessary Restraint of a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary restraint. One resident, who had diagnoses including metabolic encephalopathy, gait and mobility abnormalities, and anxiety disorder, and who was assessed as having severely impaired cognition and requiring assistance with daily activities, was reportedly tied to a wheelchair with a white sheet. Interviews with staff and another resident confirmed that residents, including this individual, were observed tied to wheelchairs or Geri chairs, often covered with blankets, and unable to move freely. Staff acknowledged that using a sheet to tie a resident to a wheelchair constitutes a restraint if the resident cannot untie themselves and exit the chair independently. There were no physician orders for restraints in the resident's medical record, and the facility's policy explicitly states that residents have the right to be free from physical restraints used for discipline or staff convenience. Despite this policy, multiple interviews indicated that the use of sheets to restrain residents occurred, particularly in the early morning hours. The Director of Nursing stated that the facility does not use restraints, but this was contradicted by staff and resident interviews.
Failure to Provide Care Plan for Mental Health and Socialization Needs
Penalty
Summary
The facility failed to provide a care plan addressing mental health services and increased socialization for a resident diagnosed with anxiety disorder and exhibiting symptoms of depression and withdrawal. The resident, who had severely impaired cognition and lacked capacity to make medical decisions, was under psychiatric care and had documented needs for emotional support and increased socialization to prevent isolation. Despite these identified needs, there was no care plan in the medical record to address the resident's mental health services, withdrawn behavior, or need for increased socialization. Observations revealed the resident was often alone, not interacting with others, and expressed feelings of sadness, boredom, and isolation. The resident reported having no friends or visitors at the facility. Staff were observed monitoring residents but not engaging with this resident. The facility's policy emphasized residents' rights to dignity, respect, and participation in social activities, but these were not reflected in the care provided to this resident.
Failure to Revise and Implement Fall Risk Care Plan After Multiple Resident Falls
Penalty
Summary
The facility failed to implement and revise a care plan for a resident assessed at high risk for falls, as required by its own policy and procedures. The resident, who had a history of falls prior to admission and multiple medical diagnoses including metabolic encephalopathy, abnormal gait, and severe cognitive impairment, was admitted with existing skin injuries and was identified as high risk for falls upon admission. The initial care plan included interventions such as visual checks every two hours, maintaining a well-lit room, keeping the bed in the lowest position, and ensuring brakes were applied during transfers. However, the care plan was not updated or revised after the resident experienced subsequent falls. On one occasion, the resident fell in the hallway while ambulating with a front-wheeled walker and sustained bruises, swelling, and an open wound on the forehead. Documentation did not indicate that staff supervised or assisted the resident during ambulation, despite the care plan's requirements. Following this fall, there was no evidence in the medical record that the care plan was updated to reflect new interventions or to address the increased fall risk, even though the resident's fall risk score increased and the physical therapist recommended supervision at all times. The resident experienced another fall in their room, resulting in additional injuries, including abrasions and bruising to the head and face. Despite these incidents and recommendations from the rehabilitation department for increased supervision, the care plan remained unchanged from its original version. Interviews with nursing staff and the Director of Nursing confirmed that the care plan was not updated after the falls, contrary to facility policy, which requires care plan updates within 72 hours of a fall to develop or revise interventions.
Failure to Activate Fire Alarm During Electrical Fire
Penalty
Summary
The facility failed to follow its own Fire Policy during an incident in which the main electrical panel room's switchboard caught fire. When smoke was discovered, staff members responded by calling 911 and notifying other staff, but did not activate the manual fire alarm system. The fire alarm did not trigger automatically, and no one pulled the nearest manual fire alarm, which was located near the exit doors by Resident Room 17 and the Director of Staff Development's office. This omission was confirmed through interviews with the Director of Staff Development and the Maintenance Supervisor, as well as direct observation of the location of the manual pull station. A review of the facility's Fire Policy indicated that staff are required to alert others over the intercom and pull the nearest fire alarm in the event of a fire. Despite this clear directive, staff did not follow the procedure, resulting in a failure to alert all individuals in the facility during the fire event. The deficiency was identified through interviews, record review, and observation, and it affected the safety of all 49 residents, staff, and visitors present at the time.
Plan Of Correction
K 0711 Corrective action for residents found to have been affected by this deficiency: On 07/28/2025, the Administrator provided a 1:1 in-service to the Director of Staff Development (DSD) and to Housekeeping 1 (HSK 1) on the Facility's Fire Policy and Procedure; and course of action for all personnel to follow in the event of a fire, including pulling the nearest fire alarm. Corrective action for residents that may be affected by this deficiency: On 07/27/2025, 07/28/2025, and 08/03/2025, the DSD provided an in-service to department heads, nurses, dietary, activity, housekeeping/laundry, maintenance, and other staff on the Facility's Fire Policy and Procedure and course of action for all personnel to follow in the event of a fire, including pulling the nearest fire alarm. Measures that will be put into place to ensure that this deficiency does not recur: During daily rounds, the DSD will randomly ask staff members on all shifts what to do in case of fire to ensure pulling the fire alarm is identified. Discussion on activating the fire alarm will be part of the monthly fire drills performed by the facility's Fire Life Safety & Security vendor. During the initial orientation, the DSD will ensure new hires will be familiar with the facility's Fire Policy and Procedure, including pulling the fire alarm. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use the indicator, "Fire Drill Program," monthly, to ensure staff
Failure to Document Four-Hour Emergency Generator Load Test
Penalty
Summary
The facility failed to provide documentation that its emergency generator underwent a required four-hour continuous load test within the past 36 months, as mandated by NFPA 110 standards. During the survey, the Administrator and DON were unable to produce written documentation of the most recent four-hour generator load test when requested. The Administrator indicated that the Maintenance Supervisor (MS) might have the documentation, but he was unavailable at the time due to being on vacation. Upon the MS's return, a generator service report dated 9/21/2021 was provided, which indicated that the emergency generator was tested for only 3 hours and 15 minutes, falling short of the required four-hour duration. No other documentation was available to demonstrate compliance with the four-hour continuous load test requirement within the last 36 months. The MS acknowledged the absence of a four-hour load test during an interview with the surveyor. The deficiency was identified through observation, interviews, and record review, and it affected all three smoke compartments of the facility. The lack of proper documentation and completion of the four-hour generator load test was confirmed by both administrative and maintenance staff during the survey process.
Plan Of Correction
has accessibility to Fire Policy & Procedure and to ensure alarm is initiated from the "fire area". The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. Corrective action for residents found to have been affected by this deficiency: On 08/03/2025, the Maintenance Supervisor witnessed a four-hour load test of the facility's emergency generator by Alliance Generators. Corrective action for residents that maybe affected by this deficiency: On 07/28/2025, the Maintenance Supervisor observed all other emergency generators. No other areas were affected by this deficient practice. Measures that will be put into place to ensure that this deficiency does not recur: has accessibility to Fire Policy & Procedure and to ensure alarm is initiated from the "fire area". The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. Corrective action for residents found to have been affected by this deficiency: On 08/03/2025, the Maintenance Supervisor witnessed a four-hour load test of the facility's emergency generator by Alliance Generators. Corrective action for residents that maybe affected by this deficiency: On 07/28/2025, the Maintenance Supervisor observed all other emergency generators. No other areas were affected by this deficient practice. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use indicator, "Physical Plant Maintenance", monthly, to ensure the generator is maintained and testing is done according to procedures outlined NFPA. The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. On 07/28/2025, the Administrator provided a 1:1 in-service to the Maintenance Supervisor to ensure a continuous four-hour emergency generator load test is conducted every 36 months. The Maintenance Supervisor will conduct an annual maintenance record review to ensure a continuous four-hour emergency generator load test is conducted within 36 months. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use indicator, "Physical Plant Maintenance", monthly, to ensure the generator is maintained and testing is done according to procedures outlined NFPA. The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025.
Failure to Implement Advance Directive Policy for Two Residents
Penalty
Summary
The facility failed to implement its Policy and Procedure on Advance Directives for two residents, leading to potential treatment against their wishes. For Resident 49, the facility did not complete the Advance Directive Acknowledgement Form upon admission, despite the resident having intact cognition and requiring assistance with daily activities. The Social Services Director confirmed that the form was not completed, which should have been done to inform the resident of their rights to refuse or accept treatment and to formulate an advance directive. For Resident 42, who had severely impaired cognition and was dependent on staff for daily activities, the Advance Directive Acknowledgement Form was not filled out completely. The Social Worker acknowledged the incomplete form and emphasized the importance of accurately documenting the resident's medical preferences. The Director of Nursing reiterated that the form should be discussed and completed upon admission to ensure the resident's medical wishes are respected in emergencies. The facility's policy, revised in 2017, mandates providing residents with information about their rights to accept or refuse treatment and to prepare an advance directive upon admission.
Failure to Assess and Notify Physician of Change in Condition
Penalty
Summary
The facility's licensed staff failed to perform a thorough assessment and notify the physician of a resident's sudden change of condition. Resident 53, who had been readmitted to the facility with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus, experienced heavy breathing and a change in face color to purple. Despite these symptoms, the Registered Nurse Supervisor did not check the resident's vital signs or notify the physician immediately, which are critical steps in managing a sudden change of condition. The Director of Nursing confirmed that the nurse should have assessed the resident's vital signs and reported the change of condition to the physician to facilitate timely treatment. The facility's policy on Change of Condition requires thorough assessment and physician notification for early clinical management, which was not adhered to in this case. This oversight had the potential to delay necessary treatments and services, contributing to the resident's health decline.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to provide necessary care and services for residents on oxygen therapy, as observed in four cases. Resident 17, who had a physician's order for continuous oxygen therapy, was found without the nasal cannula in use, and the tubing was left hanging on the oxygen concentrator. There was no care plan developed for Resident 17's use of oxygen therapy, which was confirmed by both a CNA and an LVN. The Director of Nursing (DON) acknowledged that residents with continuous oxygen orders should always be on oxygen to prevent shortness of breath and desaturation. Resident 30's oxygen tubing was not labeled with the date it was last changed, which is a requirement for infection control. The resident had an order for continuous oxygen therapy, and the facility's policy indicated that cannulas should be replaced weekly. The DON confirmed that all oxygen tubing should be labeled with the resident's name and date to ensure proper infection control practices. Resident 42 was observed with oxygen tubing touching the floor and nasal cannula prongs not properly placed inside the nostrils, which could lead to inadequate oxygen therapy. The DON stated that the nasal cannula should not touch the floor to prevent cross-contamination and should be properly placed to ensure the resident receives the prescribed oxygen. Additionally, Resident 24 was receiving oxygen therapy without a physician's order, which is against the facility's policy. The DON confirmed that a physician's order is necessary to ensure the appropriateness of oxygen therapy for residents.
Failure to Monitor Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to implement a physician's order for fluid restriction for a resident requiring dialysis care from March 1, 2025, to March 15, 2025. The resident, who was admitted with diagnoses including diabetes mellitus, hypertension, and end-stage renal disease, had a physician's order for a fluid restriction of 1000 ml every 24 hours. However, a review of the Medication Administration Record (MAR) for March 2025 revealed that there was no monitoring of the fluid restriction during this period. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the resident's fluid restriction was not monitored, which could potentially lead to fluid imbalance. The facility's policy and procedure for dialysis care indicated that the dialysis unit physician should be notified of any noncompliance with diet or fluid restrictions, but this was not adhered to. The lack of monitoring was acknowledged by the DSD and DON, who recognized the potential for fluid overload and other complications due to this oversight.
Medication Administration and Destruction Deficiencies
Penalty
Summary
The facility failed to administer medications according to its policy and procedure, specifically in the case of a resident who was prescribed Losartan for hypertension. During a medication pass observation, a registered nurse administered Losartan to the resident without checking the resident's blood pressure beforehand, as required by the physician's order. The resident's blood pressure was recorded at 105/67 mmHg the previous evening, which was below the threshold of 110 mmHg specified for withholding the medication. The nurse acknowledged the oversight, and the Director of Nursing confirmed that medications should be administered as prescribed for resident safety. Additionally, the facility did not adhere to its policy for medication destruction, which requires the presence of two licensed nurses. Records showed that 72 medications were destroyed with only one nurse signing off on the destruction forms. The Director of Staff Development and the Director of Nursing both stated that medication destruction should be witnessed by two licensed nurses to ensure safety and prevent misappropriation. The facility's policy mandates that medication destruction be documented with the signatures of two witnesses.
Failure to Ensure Kitchen Staff Wore Hairnets
Penalty
Summary
The facility failed to adhere to its policy and procedure on food preparation and serving standards, specifically regarding the use of hairnets by kitchen staff. During an initial tour of the kitchen, Kitchen Aide 1 (KA 1) was observed not wearing a hairnet while pushing a food cart with meal trays in the food preparation area. KA 1 acknowledged forgetting to wear a hairnet and recognized its importance in preventing hair from contaminating food. The Dietary Supervisor confirmed that hairnets are required for staff in the kitchen to prevent hair from falling into food or onto kitchen utensils, which could lead to contamination. The facility's undated Dietary Policy and Procedure Manual mandates that all dietary employees follow good personal hygiene practices, including wearing head coverings such as hairnets or caps while on duty. This oversight in following the established policy had the potential to cause foodborne illnesses among residents receiving food from the facility's kitchen.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 4, which was contrary to the facility's policy and procedure titled Call Lights. Resident 4 was admitted with diagnoses including paraplegia and dysphagia, and was assessed as having severely impaired cognition, making them dependent on staff for various activities of daily living. The resident was also assessed as high risk for falls due to disorientation and incontinence. Despite these conditions, during an observation, the call light was found hanging on the top of the head of the bed, out of the resident's reach, which was confirmed by both the resident and a Licensed Vocational Nurse (LVN 2). The Director of Nursing (DON) acknowledged that the call light should be within reach at all times to ensure resident safety and prevent falls. The facility's policy, dated January 2017, clearly stated that staff should ensure the call light is within easy reach when a resident is in bed or seated. This oversight had the potential to delay care or assistance for Resident 4, which could lead to falls or injuries, as the resident was unable to independently access the call light to request help.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to ensure the accurate coding of a resident's Minimum Data Sheet (MDS), which is a critical resident assessment tool. This inaccuracy was identified for a resident who was discharged from the facility. The resident, who had been admitted with conditions including cellulitis, seizures, and anemia, was discharged with an order for home health care services. However, the MDS inaccurately indicated that the resident was discharged to a short-term general hospital instead of home. Interviews with the MDS Coordinator and the Director of Nursing confirmed the discrepancy, with both acknowledging the importance of accurate MDS coding for continuity of care and accurate reporting to the Centers for Medicare & Medicaid Services (CMS). The facility's policy on the Resident Assessment Instrument (RAI) process emphasizes the need for accurate assessments of residents' functional capacity and health status, which was not adhered to in this case.
Medication Administration Documentation Error
Penalty
Summary
The facility failed to ensure that medications were administered before being documented as given in the Electronic Medication Administration Record (EMAR) for a resident. During a medication pass observation, a registered nurse supervisor was unable to unclog the resident's gastrostomy tube and could not administer the scheduled 9:00 am medications. Despite this, the nurse marked ten medications as given in the EMAR before they were actually administered. The resident involved had a history of severe cognitive impairment and was dependent on staff for personal care. The facility's policy and procedure on medication administration clearly stated that medications should be documented in the EMAR only after they have been administered. Both the registered nurse and the Director of Nursing acknowledged that documenting medications before administration could lead to missed doses and medication errors, which was inconsistent with the facility's policy.
Failure to Administer Enteral Feeding as Prescribed
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (GT) received necessary treatment and services as per the facility's policy and procedure on enteral feedings. The resident, who was admitted with diagnoses including paraplegia and dysphagia, had severely impaired cognition and was dependent on staff for various daily activities. The resident's order summary indicated that Glucerna 1.2 formula was to be administered via an enteral pump machine at a specific rate and duration. However, during an observation, it was found that the GT feeding bottle was unlabeled, and the enteral pump machine was turned off, contrary to the prescribed continuous administration. Licensed Vocational Nurse 2 admitted to hanging the feeding but not turning on the machine until later, which was necessary to prevent dehydration and electrolyte imbalance. The Director of Nursing confirmed that the GT bottle formula should have been labeled with the resident's name, date, time, and the nurse's signature to ensure the correct feeding was administered. The facility's policy on enteral feedings required documentation on the formula label to prevent errors, which was not adhered to in this case.
Failure to Document Medication Administration and Monitoring
Penalty
Summary
The facility failed to document the administration of Hydralazine and blood glucose monitoring for two residents, leading to potential medication errors. For Resident 37, the Medication Administration Record (MAR) did not show that Hydralazine was given at 6 am or that blood glucose monitoring was performed at 6:30 am on 3/13/2025. The resident was admitted with diagnoses of diabetes mellitus and hypertension and was independent in personal hygiene and transfers. The Director of Staff Development and the Director of Nursing both emphasized the importance of signing the MAR immediately after medication administration and monitoring to prevent missed doses or overdoses. For Resident 42, the MAR did not indicate that blood glucose monitoring was performed on 3/13/2025 as ordered. The resident, who was admitted with pneumonia and type 2 diabetes mellitus, had severely impaired cognition and was dependent on staff for daily activities. During an interview, a registered nurse acknowledged that the MAR was not signed and could not explain why the monitoring was not documented. The facility's policy requires that medication administration and monitoring be recorded immediately to ensure resident safety.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that six of 23 resident rooms met the square footage requirement of 80 square feet per resident in multiple resident rooms. Specifically, Rooms 2, 8, 10, 11, 15, and 16 did not meet the minimum square footage requirement. Room 2, which housed four residents, measured 286.92 square feet, falling short of the 320 square feet required for a four-bed room. Rooms 8, 10, 11, 15, and 16, each housing two residents, measured between 147.50 and 152.24 square feet, below the 160 square feet required for two-bed rooms. During observations, it was noted that residents in these rooms were able to ambulate freely and nursing staff had sufficient space to provide care with dignity and privacy. Interviews with the residents did not reveal any concerns regarding the size of their rooms. The facility had submitted a room waiver request, indicating that there was enough space for nursing care and that the health and safety of the residents were not in jeopardy. The waiver also stated that the room sizes were in accordance with the needs of the residents and would not adversely affect their health and safety or impede their ability to attain their highest practicable well-being.
Failure to Notify Responsible Party of Resident's Fall
Penalty
Summary
The facility failed to notify the responsible party of a resident's fall, which occurred while the resident was under the facility's care. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, urinary tract infection, and dementia, was found on the floor next to her bed early in the morning. Despite the fall being documented in the resident's Situation-Background-Appearance-Review and Notify Communication Form (SBAR), the responsible party, who is the resident's daughter, was not informed of the incident. The Licensed Vocational Nurse (LVN) involved confirmed that although a call was made, no detailed voicemail was left, and the responsible party was not directly informed about the fall. The Director of Nursing (DON) acknowledged that charge nurses are required to notify family members or responsible parties when a resident experiences a fall. However, it was revealed that the facility lacked a policy and procedure regarding the notification of responsible parties about residents' falls or changes in condition. This oversight in communication and procedural guidelines led to the responsible party being unaware of the resident's fall, despite the facility's obligation to keep them informed of any changes in the resident's health status.
Failure to Conduct Daily Skin Assessments for At-Risk Resident
Penalty
Summary
The facility failed to provide a daily skin assessment for a resident who was at risk of developing skin breakdown and pressure injuries. The resident, who had been admitted and readmitted to the facility, had diagnoses including type 2 diabetes mellitus, metabolic encephalopathy, and dysphagia. The Minimum Data Set (MDS) indicated the resident was severely impaired in cognitive skills and required assistance for daily activities. Despite being at risk for pressure injuries, the resident's daily skin assessments were not conducted as required, and existing skin conditions were not documented accurately. During observations and interviews, it was noted that the resident had a healing laceration on the nose and discoloration under the eyes, which were not documented in the admission assessment or daily skilled nurse's notes. The Assistant Director of Nursing and a Registered Nurse confirmed that the daily notes were completed without a physical assessment, relying instead on outdated information from the admission assessment. The Director of Nursing stated that daily notes should include a physical assessment to ensure accurate documentation and treatment of skin issues. The facility's policy required a baseline care plan to address health care information, goals, and objectives, which was not adhered to in this case.
Inaccurate Documentation of Skin Assessments
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident, identified as Resident 8, by not accurately documenting skin assessments. Resident 8 was admitted with diagnoses including type 2 diabetes mellitus, metabolic encephalopathy, and dysphagia. The Minimum Data Set (MDS) indicated that Resident 8 was at risk of developing pressure injuries and had open lesions other than ulcers, rashes, or cuts. However, during a review of Resident 8's Comprehensive Resident Assessment (AA), it was found that the assessment did not document a laceration on Resident 8's nose and discoloration around the eyes, which were present upon readmission. The Assistant Director of Nursing (ADON) and Treatment Nurse (TN) 1 acknowledged the omission of these injuries in the documentation. Additionally, Registered Nurse (RN) 1 admitted to copying the skin assessment information from the AA without conducting a physical assessment, leading to further inaccuracies in the Daily Skilled Nurse's Notes. The Director of Nursing (DON) confirmed that nurses are required to physically assess residents to ensure accurate documentation of skin issues. The facility's policy on documentation principles emphasizes the need for accurate, timely, and descriptive entries, which was not adhered to in this case.
Incomplete Documentation of Diagnostic Follow-Up
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Documentation Principles' by not maintaining complete documentation for a resident who underwent a diagnostic service. The resident, admitted with conditions including parkinsonism, pneumonia, and dysphagia following a stroke, had a scheduled video swallow study to evaluate swallowing difficulties. Although the resident attended the appointment, there was no documented follow-up in the resident's chart regarding the results of the video swallow test, which was crucial for ensuring appropriate care and treatment. The Director of Nursing acknowledged the importance of documenting follow-up actions to prevent complications, especially for residents with aspiration precautions. Despite the Assistant Director of Nursing contacting the hospital's radiology department to inquire about the test results, this follow-up was not recorded in the resident's chart. The facility's policy required that if diagnostic service reports were not received within 48 hours, the service should be contacted immediately, and a copy of the report requested. The lack of documentation in this case represents a failure to comply with the facility's established procedures for maintaining current and detailed clinical records.
Failure to Provide Adequate Hydration Leads to Severe Health Complications
Penalty
Summary
The facility failed to provide adequate hydration for a resident, leading to severe health complications. The resident, who had a history of dysphagia, chronic kidney disease, and impaired cognition, was assessed to require 1950 mL to 2040 mL of fluids per day. However, from the period of May 16, 2024, to June 1, 2024, the resident consistently received less than the required amount of fluids, with daily intake ranging from 120 mL to 930 mL. This inadequate fluid intake was not properly monitored or addressed by the facility staff, despite the resident's care plan indicating a risk for dehydration and the need for monitoring fluid intake and output. The facility's staff, including CNAs and LVNs, failed to ensure the resident received the necessary fluids and did not adequately monitor or report the resident's fluid intake. The CNAs did not report any issues with the resident's fluid intake to the LVNs, and the LVNs were unaware of the resident's fluid requirements and did not notify the resident's physician or dietician about the inadequate fluid intake. The resident's altered level of consciousness and other symptoms on June 1, 2024, led to an emergency transfer to a hospital, where the resident was diagnosed with hypernatremia, dehydration, uremia, and acute kidney injury. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's fluid needs and intake. The Director of Nursing acknowledged that the staff should have been aware of the resident's fluid requirements and should have reported any changes in the resident's condition to the appropriate medical personnel. The facility's policies on hydration management and intake and output monitoring were not effectively implemented, contributing to the resident's severe dehydration and subsequent hospitalization.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, as required by their policy and procedure on significant change in condition. The resident, who had a history of dysphagia, chronic kidney disease, and impaired cognition, was noted to struggle with fluid intake and required encouragement to drink. Despite these observations, the licensed vocational nurses (LVNs) did not promptly notify the resident's primary physician or obtain a physician's order to monitor the resident's intake and output, which was necessary to address the resident's potential for fluid-electrolyte imbalance related to hypernatremia. The resident's laboratory results showed elevated serum sodium levels, indicating hypernatremia, which could suggest dehydration. The resident's fluid intake was consistently below the estimated daily requirement, as documented in the facility's records. However, the registered dietician (RD) was not informed of the resident's inadequate fluid intake, and the LVNs did not communicate this critical information to the physician. The lack of communication and failure to act on the resident's fluid intake needs resulted in the resident being transferred to a general acute care hospital with diagnoses of hypernatremia, dehydration, uremia, and acute kidney injury. Interviews with facility staff, including the director of nursing (DON), LVNs, and certified nursing assistants (CNAs), revealed a lack of awareness and communication regarding the resident's fluid needs and the significance of the resident's condition. The facility's policy required immediate reporting of changes in resident status to licensed personnel and the nursing supervisor, but this protocol was not followed. The failure to notify the physician and obtain necessary orders led to a delay in providing appropriate care and treatment for the resident.
Unsafe Discharge of Resident
Penalty
Summary
The facility failed to provide a safe discharge for a resident who was discharged 497 miles away from the facility with nowhere to stay. The resident had diagnoses including abnormalities of gait and mobility, unspecified psychosis, and Type 2 diabetes mellitus. Despite having intact cognition, the resident required assistance for various activities of daily living. The discharge care plan indicated a potential discharge to home with assistance, but the family member explicitly stated that the resident could not come to their home and that they were not obligated to take care of the resident. Despite this, the facility proceeded with the discharge, believing the resident had arranged everything. Upon discharge, the resident was left at the Social Services department with belongings but no place to stay. The family member reiterated their inability to care for the resident, and the resident ended up in the welfare department and later in a motel with no further accommodation arranged. The facility's policy on discharge planning required re-evaluation and updates to the discharge plan, considering caregiver availability and capability, which was not adequately followed in this case. The Social Services Director and Director of Nursing were informed of the resident's situation but believed the discharge was safe based on the resident's statements, which proved to be inaccurate.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, resulting in the presence of fruit flies in both a resident's room and the conference room. During an observation, a fruit fly was seen flying in front of a resident's face, causing the resident to move away from it. Another observation noted a fruit fly in the conference room. Interviews with the Maintenance Supervisor and the Director of Nursing revealed that the facility's doors needed to be kept closed to prevent pests and that the pest control company should be called when fruit flies are present. The facility's policy indicated that pests should be managed using a pest management company, with routine and additional services as needed.
Failure to Provide Reasonable Accommodation for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for two residents. For Resident 1, who was admitted with diagnoses including unspecified dementia and required assistance with personal care, the call light was not within reach. Observations revealed that the call light was under the bed of Resident 1's roommate, making it inaccessible. Both the Infection Preventionist Nurse and the Director of Nursing confirmed that the call light should have been within reach to ensure timely assistance and maintain Resident 1's safety. The facility's policy also indicated that call lights should be within easy reach of residents when they are in bed or in a wheelchair or chair in the room. For Resident 38, who had intact cognition and no impairments in upper or lower extremities, the facility failed to adjust the clock in the resident's room after Daylight Saving Time. Despite Resident 38's requests to staff to change the time, the clock continued to display an hour earlier than the actual time, causing confusion for the resident. The Licensed Vocational Nurse acknowledged that the clock was not adjusted and stated that it should reflect the actual time to avoid confusion for residents. The facility's policy emphasized providing a safe, clean, and comfortable environment for residents.
Failure to Follow Advance Directive Policy
Penalty
Summary
The facility failed to follow its policy and procedure titled, Advance Directive, for two of three sample residents. For Resident 38, the facility did not provide information regarding Advance Directives (AD) upon readmission, despite the resident having intact cognition and the capacity to understand and make decisions. The Social Service Director (SSD) confirmed that there was no documentation indicating that AD information was offered to Resident 38, which is crucial for ensuring that the resident's treatment preferences are known and respected by the staff. For Resident 18, the facility failed to ensure that the AD copy was readily retrievable in the resident's medical records. Resident 18 had severely impaired cognition and required total dependence on staff for daily activities. Despite having an AD upon admission, the SSD was unable to locate the AD in the medical record, and the resident and their responsible party were unaware of its existence. The Director of Nursing (DON) also confirmed that the AD should be easily accessible in the medical record for immediate access in case of an emergency.
Failure to Report and Investigate Resident Injuries
Penalty
Summary
The facility failed to provide safety and protection for a resident who had injuries from an unknown source. The staff did not immediately report the resident's injuries to the Department of Public Health (DPH), Ombudsman, and local law enforcement within the required two-hour timeframe. Additionally, the staff did not investigate the injuries in accordance with the facility's policy and procedures for resident abuse prevention, nor did they notify the resident's physician and responsible party about the injuries. These deficiencies compromised the resident's safety and protection from potential abuse in the facility. The resident, who was admitted with diagnoses including dementia and chronic kidney disease, was observed with dark red-purple skin discoloration and a bump on the forehead, as well as dark purple skin discoloration below both eyes. The resident was non-communicative, and the injuries were first noticed by family members during a visit. Despite the family members' inquiries, the staff did not provide specific information about the cause of the injuries, and there was no documented evidence of an incident or fall in the resident's medical record. Interviews with staff revealed that they were aware of the resident's injuries but did not know how they occurred. The injuries were not reported or investigated as required by the facility's policy. The Director of Nursing (DON) and the Administrator were also unaware of the injuries until the survey. The facility's policy on abuse reporting and prevention mandates that injuries of unknown sources be reported within two hours to ensure resident rights are protected, but this protocol was not followed in this case.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that residents receiving oxygen therapy were provided with respiratory care in accordance with the facility's policy and procedure. Specifically, Resident 25's nasal cannula tubing was observed touching the floor, and there was no cautionary sign posted on the door indicating oxygen was in use. Resident 25 had severe impaired cognition and was totally dependent on staff for daily activities. The Licensed Vocational Nurse (LVN) confirmed that the nasal cannula tubing should not touch the floor to prevent cross-contamination and that a smoking sign should be posted to avoid fire hazards. The Director of Nursing (DON) reiterated these points during an interview, emphasizing the importance of preventing infections and ensuring safety by posting appropriate signage. The facility's policy on oxygen administration and storage of oxygen cylinders also required such precautions, which were not followed in this case. Similarly, Resident 45's nasal cannula tubing was not labeled, and it was also observed touching the floor. Additionally, there was no precautionary signage posted on Resident 45's door indicating oxygen was in use or that smoking was prohibited. Resident 45 had severe cognitive impairment and was totally dependent on staff for daily activities. The LVN confirmed the absence of the required signage, and the DON stated that such signs should be posted to inform visitors and residents about the oxygen therapy and to prevent fire hazards. The facility's policies on oxygen administration and storage of oxygen cylinders were not adhered to, leading to this deficiency.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week from March 1, 2024, through March 15, 2024, for 12 of 15 days. During an interview and record review on March 15, 2024, with the Director of Staff Development (DSD), it was revealed that the nurse staffing sign-in sheet for the month of March 2024 indicated no RN was on duty for twelve days. The DSD confirmed that the facility had no full-time RN working eight hours per day, seven days a week since February 2024. The facility's policy and procedures (P&P) titled 'Staffing' dated March 2020 indicated that RN staff should be available to provide and monitor the delivery of resident care services. The DSD emphasized the importance of having a full-time RN to oversee residents' assessment and care in the facility every day.
Sanitizing Solution Concentration Deficiency
Penalty
Summary
The facility failed to ensure that the sanitizing solution used for cleaning the food preparation area had the correct concentration to meet industrial standards. During a tour of the facility's kitchen, it was observed that one of the three red buckets containing sanitizing solution had a concentration of 100 parts per million (ppm) instead of the recommended 200 ppm. The Dietary Assistant (DA) confirmed that the solution should reach 200 ppm to effectively kill bacteria and viruses. The DA acknowledged that a concentration below 200 ppm would not fully sanitize the countertops, potentially leading to contamination and foodborne illness among residents. In an interview, the Dietary Supervisor (DS) stated that the facility used Multi-Quat Sanitizer from Ecolab and that the solution in the red buckets should be changed every two hours or as needed. The DS reiterated that the solution should reach 200 ppm to prevent contamination and foodborne illness. A review of the facility's undated Policy and Procedure Manual confirmed that manual sanitizing should be accomplished with a solution of 200 ppm quaternary ammonium for one minute.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for Resident 204, who had severe cognitive impairment and required total assistance for daily activities. Resident 204 was readmitted to the facility with diagnoses including abnormalities of gait and mobility, muscle wasting, and a contracture of the left hand. The resident's care plan specifically indicated that the call light should be within reach to mitigate fall risk and ensure timely assistance from staff. However, during an observation, the call light was found clipped to the pillow and not within the resident's reach. Certified Nursing Attendant 1 confirmed that the call light should have been within reach. The Director of Nursing also acknowledged that the call light needed to be within reach to maintain the resident's safety and ensure timely response to the resident's needs. The facility's policy and procedure on call lights, revised in January 2017, also stipulated that the call light should be within easy reach of the resident when in bed. This deficiency was identified through a combination of observation, interviews, and record reviews, highlighting a failure to adhere to established protocols designed to ensure resident safety and timely care.
Failure to Obtain Informed Decision for Non-Covered Services
Penalty
Summary
The facility failed to obtain an informed decision from Resident 17's representative regarding payment for non-covered services after the resident was discharged from Medicare Part A. Resident 17, who was admitted with diagnoses including dementia and hypertensive heart disease, continued to reside in the facility after the last covered day of Medicare Part A services. The Business Office Manager (BOM) issued the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) but did not follow up to ensure the resident's representative was informed about financial responsibilities. The BOM mistakenly checked an incorrect option on the form and did not make a follow-up call to obtain an informed decision from the representative.
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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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