Vermont Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrance, California.
- Location
- 22035 S. Vermont Avenue, Torrance, California 90502
- CMS Provider Number
- 056433
- Inspections on file
- 58
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 33 (1 serious)
Citation history
Health deficiencies cited at Vermont Healthcare Center during CMS and state inspections, most recent first.
An LVN did not administer multiple scheduled meds within the required time window for many residents during a morning med pass, and one resident with a g-tube and diagnoses including CVA-related deficits, seizures, and HTN received several meds late after the pass was delayed by a clogged g-tube valve. In addition, pregabalin documentation for another resident was inaccurate because the LVN removed the controlled med from the AM bubble pack but recorded it on the wrong CDR page, leaving the bubble pack count and CDR out of sync.
Medication Storage and Labeling Deficiencies: Multiple meds were found stored or labeled contrary to manufacturer instructions and facility policy. Two residents’ gabapentin oral solutions were kept in med carts instead of the refrigerator, two residents had insulin pens that were expired and/or missing open dates in a med cart, and a resident’s morphine sulfate oral solution was stored in a refrigerator despite requiring controlled room temperature storage. Staff interviews confirmed the storage and labeling errors, and the MAR showed potential administration of expired insulin.
The facility failed to follow infection control practices for several residents. Two residents had foam-wrapped side rails cleaned with disinfectants intended for nonporous surfaces, a resident’s PIV remained in place after IV antibiotics were completed, a CNA entered a resident’s room and donned gloves without hand hygiene, and a resident’s suprapubic catheter drainage bag was observed on the floor. Staff and the DON acknowledged the observed practices and stated they were not consistent with infection control expectations.
Unclear indication and diagnosis for Seroquel use: A resident with dementia, anxiety, depression, and ETOH-related diagnoses received Seroquel for agitation, wandering, screaming, and mood instability, but consultant pharmacist reviews repeatedly requested clarification of the underlying diagnosis and appropriate behavior. A physician note later changed the indication to mood instability with agitated outbursts, while the MAR showed ongoing administration of Seroquel 25 mg and then 50 mg BID. Staff stated the resident should have been evaluated by psychiatry, and the DON said the psych consult was not uploaded into the EHR.
Inaccurate MDS Coding of Oral and Dental Status: A resident with DM, schizoaffective disorder, depression, and HTN was documented as edentulous in the dietary assessment and care plan, but the MDS incorrectly coded the resident as having natural teeth. The resident was observed to have no natural teeth and reported dentures caused pain. The MDS nurse stated the assessment was not coded correctly, and the DON stated inaccurate assessment affects the resident’s plan of care.
Failure to complete required PASRR Level II evaluation: A resident with paranoid schizoaffective disorder, major depressive disorder, anxiety disorder, and moderate cognitive impairment had a PASRR Level I screening that required a Level II mental health evaluation for SMI. Facility staff did not respond to repeated communication attempts, the Level II case was closed without completion, and MDSN and the DON stated the task was overlooked because no staff member took ownership of it.
A resident with paranoid schizoaffective disorder, major depressive disorder, anxiety disorder, and moderate cognitive impairment was identified through PASRR Level I screening as needing a Level II evaluation, but the EHR contained no individualized, interdisciplinary care plan for the resident’s mental health or specialized service needs. The MDS nurse and DON confirmed the care plan was missing, and the DON stated the facility failed to complete the PASRR Level II because staff assignment for follow-up was unclear.
A resident with chronic respiratory failure, encephalopathy, sepsis, a trach, G-tube, and foley was dependent for multiple ADLs and required 2- to 3-person assist for turning. During incontinent care, a CNA provided care alone instead of the required 2-person assistance, while the resident coughed intermittently. The CNA said the other staff member was busy, and the RNS and DON confirmed the resident needed at least two staff for turning and incontinent care per the task list and care plan.
Failure to Provide Oral Hygiene for a Dependent Resident: A resident with dysphagia, emphysema, muscle wasting, and severe cognitive impairment was dependent on staff for oral hygiene, but was found with a brown, sticky substance coating the roof of the mouth, tongue, teeth, and lips. The resident said the mouth had not been cleaned for a while. The RNS began mouth care after observing the condition, and the assigned CNA stated she had not provided oral care because the resident had a mouth sore and she was unsure whether CNA or nursing staff should clean the mouth.
Failure to Ensure Fall Prevention and Safe Meal Positioning A resident with a high fall risk, impaired cognition, and a history of falls was found on the floor after staff did not identify the resident as high risk, did not ensure the bed pad alarm was functioning, and did not notice the resident scooting toward the doorway. In a separate incident, another resident who needed substantial assistance with bed mobility was left slouched in bed during lunch when a CNA delivered the meal tray without repositioning the resident upright, and the CNA stated she forgot to return after seeking help.
Improper Foley Drainage Bag Positioning: A resident with an indwelling Foley catheter, urinary retention, and severely impaired cognition had the drainage bag left on top of the bed during personal care for about 10 minutes while it was filled with urine. The CNA said the bag was placed there to prevent accidental pulling, while the DON stated the bag should be kept below bladder level and the facility policy required drainage bags to always remain below bladder level.
Failure to Provide Adequate Hydration to a Visually Impaired Resident: A resident with glaucoma, bilateral vision loss, dysphagia, and DM2 required substantial to maximal assistance with eating and oral hygiene, yet was observed with an empty water pitcher, no fluids within reach, and a bedside table placed out of reach. The resident representative reported the facility did not provide water throughout the day and said the resident had recently required IV fluids for dehydration after severe dizziness. Staff and the DON acknowledged the resident needed active assistance, prompting, and fluids kept within reach to maintain hydration.
Expired Tube Feeding Formula Left Connected to a Resident: A resident with anoxic brain damage, dysphagia, and a gastrostomy tube was observed with an enteral feeding pump off but still connected and a tube feeding bag that staff said had exceeded the 24-hour limit after opening. Staff confirmed the formula was no longer safe after 24 hours, and the facility policy required accurate labeling and dating of each feeding bag or formula container.
A resident with multiple sclerosis, respiratory failure, sepsis, and severely impaired cognition received IV Vancomycin for pneumonia, but the IV dressing was not labeled with the insertion date, time, or staff initials. During the infusion, the RN supervisor later found the IV had infiltrated with redness and swelling. Facility policy required IV site labeling and ongoing assessment for infiltration, phlebitis, and infection.
A resident with hydrocephalus, chronic respiratory failure, and intracranial hemorrhage was observed receiving oxygen via NC without a date label on the tubing. The RNS confirmed the flow rate was set at 3 L/min instead of the ordered 2 L/min PRN to keep O2 sat above 92%, and the DON stated staff were expected to date NC tubing and follow the physician's order. Facility policy required the oxygen flow rate to match the order and the tubing to be dated when initiated or replaced.
Failure to Enforce Ordered Fluid Restriction: A resident with ESRD, CHF, dialysis dependence, and DM had a physician-ordered 1000 ml/24-hour fluid restriction, but staff did not consistently monitor, document, or enforce intake. The resident was observed with edema and multiple beverages at bedside, a CNA did not know the fluid allowance or track intake, and MAR review showed repeated daily totals above the ordered limit. An LPN acknowledged the resident had edema, crackles, and weight gain and had not reported these findings to the physician.
A resident received quetiapine for agitation and mood instability, but the consultant pharmacist repeatedly requested clarification of the underlying diagnosis during monthly MRRs and the record did not show consistent follow-through. The chart contained varying diagnoses and notes about restlessness, wandering, and agitated outbursts, while the DON stated the psych consult was not uploaded into the EHR and the LVN could not find psychiatrist notes. The facility’s MRR and psychotropic medication policies required documented clinical indication/diagnosis and prompt response to irregularities.
Failure to Monitor Opioid Side Effects: A resident with chronic pain, heart failure, and impaired mobility was receiving Oxycodone and Morphine Sulfate for pain, but the MAR and order review showed no documented monitoring for opioid side effects. The RNS and DON stated that known opioid effects include depressed respirations, low BP, cold and clammy skin, sedation, and CNS depression, and that licensed nurses should monitor for these reactions.
Medication pass errors exceeded the allowed threshold when an LVN gave a time-critical anti-seizure medication outside the required window for one resident and failed to flush a g-tube before and after administering psyllium husk for another resident. The residents had significant neurologic and feeding-tube-related conditions, and the MAR, observation, and staff interviews showed the doses were not given in accordance with the physician orders and facility policy.
An LVN administered a resident’s Keppra via g-tube outside the facility’s required medication window, and the MAR documentation did not match the observed administration time. The resident had seizures, stroke-related deficits, and was dependent on staff for care. Audit findings showed repeated late doses of levetiracetam, and staff interviews confirmed the medication was given more than one hour late despite policy identifying anti-seizure meds as time-critical.
Uncovered facial hair during kitchen food prep: An AM Cook and the Assistant Dietary Supervisor were observed working in the kitchen prep area without beard restraints while handling and preparing food. The DS stated beard restraints were used during service but not during prep, and beard nets were stored in a box under a desk rather than being readily available at the kitchen entrance. Facility policy and cited FDA/CFR standards required beard covers for facial hair.
A resident with chronic respiratory failure, ventilator dependence, and atrial fibrillation had weights documented as 200 lbs, 199 lbs, and then 97.8 lbs, reflecting a large loss. The RNS stated there was no documentation of the weight loss, no recheck weight, no COC assessment, no MD notification, and no follow-up with the RD; the DON stated the weight should have been reassessed immediately to verify accuracy.
A resident with severe cognitive impairment, schizoaffective disorder, psychosis, seizures, high elopement risk, and high fall risk was discharged to a recuperative care center (RCC) without proper discharge planning. The conservator, identified as the responsible party, was not involved in selecting the RCC or consenting to the discharge, and no IDT meeting was held to assess the resident’s cognitive, medical, physical, or psychosocial needs before transfer to a lower level of care. Nursing staff did not complete required steps such as effective communication with the receiving facility, medication reconciliation, or a direct nurse-to-nurse handoff, and only a voicemail was left for the conservator after the resident had already been transferred. EMS and hospital records later documented that the resident was found wandering in the community, disoriented, and was admitted to a GACH with acute psychosis and altered mental status, leading surveyors to cite noncompliance with F-627 for failure to ensure a safe discharge.
A resident with a Foley catheter was observed in a wheelchair in the hallway without a dignity bag covering the catheter bag. The resident confirmed not having or using a dignity bag. Staff interviews revealed that the CNA was unaware of the catheter and did not cover it, and the LVN did not notice the catheter bag. Facility policy requires Foley catheters to be covered to maintain privacy and dignity.
A resident with severe cognitive impairment and multiple medical conditions was involved in an altercation with another resident. Following this incident, the facility did not conduct an IDT meeting to review and revise the care plan, as required by policy. Staff interviews confirmed the absence of an IDT meeting after the change in condition, resulting in a delay in addressing the resident's care needs.
A resident with diabetes, chronic kidney disease, and quadriplegia did not receive consistent blood sugar monitoring or insulin coverage as required by facility policy and physician orders. Staff were unaware of the resident's diabetes diagnosis and did not monitor for symptoms of hyperglycemia or hypoglycemia. The resident's PCP was not informed about the lack of blood sugar checks, leading to a critical event where the resident developed diabetic ketoacidosis with coma and required emergency hospitalization.
A resident with severe cognitive impairment and total dependence for ADLs was not promptly readmitted after hospital stabilization due to reported lack of bed availability, resulting in a three-day delay despite facility policy requiring return to the first available bed.
A resident with severe cognitive impairment and physical limitations was not assisted with showers at least twice weekly, despite care plan directives and facility policy. Documentation and staff interviews confirmed the lack of required ADL support, resulting in unmet hygiene needs.
A tube of Diclofenac Sodium Topical Gel, 1% that was not part of a resident's current physician-ordered medications was found left on the resident's nightstand. Both an RN and the DON confirmed that medications should not be stored at the bedside and should only be accessible to authorized staff, in accordance with facility policy.
A resident with a history of falls and multiple fractures did not receive the required visual checks as outlined in their care plan, and staff failed to document these interventions. This lapse resulted in an unwitnessed fall causing pelvic fractures and hospitalization, despite facility policies mandating comprehensive care planning and documentation.
A resident with paraplegia, dependent for transfers, was manually moved from bed to a shower chair by a CNA and RNA without using a mechanical lift as recommended by PT and required by facility policy. The resident, who was cognitively intact, requested not to use the lift due to discomfort, and staff did not escalate the refusal. During the manual transfer, the resident was assisted to the floor and sustained a minimally displaced impacted femur fracture. The facility lacked a care plan intervention for mechanical lift use and staff did not follow fall prevention and transfer policies.
A resident with a tracheostomy and severe cognitive impairment experienced bleeding and severe pain at the stoma site after a tracheostomy tube change. Despite a physician's order to notify the physician for severe pain, an LPN administered Tylenol but did not contact the physician. Documentation and staff interviews confirmed the lack of required notification, leaving the physician unaware of the resident's change in condition.
The facility failed to conduct Change in Condition (CIC) evaluations for three residents exposed to COVID-19, despite orders for novel respiratory precautions. These residents, with varying levels of cognitive impairment and dependency on assistance for daily activities, did not receive the required assessments following their exposure. Interviews with staff confirmed the absence of CIC evaluations, contrary to the facility's policy for significant changes in condition.
Staff at the facility failed to wear proper PPE when entering rooms under Novel Respiratory Precautions for COVID-19 exposure. A housekeeping staff member, a CNA, and a Charge Nurse entered the rooms of three residents without the required gown, eye protection, filtered mask, and gloves. The facility's policy mandates full PPE for such precautions, which was not followed, as confirmed by the Infection Preventionist and DON.
A resident at high risk for pressure injuries developed deep tissue injuries on the right lateral foot and right buttock due to the facility's failure to turn and reposition the resident every two hours as per the care plan and physician orders. Additionally, regular skin assessments were not conducted, and preventive measures like Prevalon boots were not applied in a timely manner, leading to the deterioration of the resident's skin condition.
The facility failed to administer morning medications on time in the SAU, with delays due to the lengthy process of administering via G-tubes. Additionally, two residents received Zosyn IV medications that did not match physician orders due to uncommunicated changes by the pharmacy. The emergency drug usage log was also incomplete, lacking essential details.
Two residents in an LTC facility received intravenous antibiotics not in accordance with physician orders, with Zosyn administered in normal saline instead of dextrose, potentially affecting their health due to existing conditions. Additionally, a resident with hypothyroidism missed doses of Liothyronine, as confirmed by medication records and staff interviews. The facility's Medication Administration Policy was not followed, increasing the risk of adverse health outcomes.
The facility failed to provide adequate ROM and mobility services to residents, as evidenced by inconsistent adherence to physician orders and therapy recommendations. A resident with hemiparesis did not receive PROM exercises for both arms, and AAROM exercises for both legs were inconsistently documented. Another resident with anoxic brain damage did not receive consistent PROM exercises or have prescribed splints applied regularly, leading to potential contractures. Additionally, a resident with cerebral infarction did not receive prescribed Omni-cycle exercises and ambulation assistance, affecting joint and muscle integrity.
The facility failed to provide adequate staffing of Restorative Nursing Aides (RNAs) and licensed nurses, resulting in missed treatments for residents with limited range of motion and delayed medication administration in the subacute unit. Several residents did not receive their prescribed RNA services due to insufficient staffing, and medication administration was delayed for some residents due to a lack of licensed nurses.
The facility exceeded the 5% medication error rate threshold, with errors involving two residents. A resident received Mucinex DM instead of Mucinex (guaifenesin) as ordered, and another received Zosyn in normal saline instead of dextrose. The errors were due to incorrect medication preparation and administration by nursing staff.
The facility failed to ensure IV antibiotic medications were labeled according to physician orders for two residents. One resident received piperacillin sodium and tazobactam sodium (Zosyn) in normal saline, contrary to the order for the medication in dextrose for a UTI. Another resident's medication label also did not match the order for Zosyn in dextrose for pneumonia. These discrepancies could lead to medication errors.
The facility failed to ensure the ice machine had an air gap for backflow prevention, as required by the FDA Food Code. Observations revealed black grime and dirt on the ice machine pipe, with no air gap present. Staff, including the Assistant Dietary Supervisor, Registered Dietician, and Maintenance Supervisor, were unaware of the regulation. The Administrator acknowledged the potential risk of contaminated water backflowing into the ice machine, posing a risk of waterborne illness to residents.
The facility failed to accurately document care for several residents, leading to deficiencies in treatment. A resident's AAROM exercises were not documented for the right leg, another's PROM for the left arm was incorrectly scheduled, and Omni-cycle exercises for both arms were omitted. Additionally, a clinical record error persisted for months, and splint applications and speech-language pathology treatment attempts were not documented, resulting in inaccurate care provision.
The facility failed to maintain proper infection control practices, including maintaining appropriate dryer temperatures, performing hand hygiene, and disinfecting cloth gait belts. A dryer was operating below the required temperature to kill germs, a CNA did not perform hand hygiene between resident rooms, and a Laundry Aid handled clean linens without washing hands after sorting dirty ones. Additionally, cloth gait belts were improperly disinfected with wipes meant for non-porous surfaces, risking infection spread among residents with serious health conditions.
The facility failed to maintain operational washer temperature gauges, with staff using incorrect methods to check temperatures, risking infection spread. The Maintenance Supervisor and Laundry Aide used sink water temperatures instead of the non-functional gauges, contrary to the facility's policy requiring 160°F for linen washing. The Director of Nursing highlighted the importance of accurate washer temperatures to prevent resident infections.
The facility failed to notify the physician and complete a Change of Condition (COC) for two residents. One resident expressed a desire to die, and another missed thyroid medication doses. Staff acknowledged the oversight, and the facility's policies require immediate physician notification for significant changes.
A resident with serious mental illness was admitted without a required PASARR Level II evaluation, despite a Level I screening indicating its necessity. The oversight was confirmed by the MDS coordinator and DON, acknowledging the potential for missed specialized mental health services.
A facility failed to implement a care plan for a resident with paranoid schizophrenia and major depressive disorder who expressed a desire to die. Despite staff acknowledging the need for a care plan to address the resident's suicidal ideation, none was in place, contrary to the facility's policy on comprehensive care plans.
A resident admitted with multiple fractures did not have an Interdisciplinary Team (IDT) meeting scheduled within the required 72 hours, as per facility policy. This oversight left the resident unaware of his care plan. Interviews with staff confirmed the failure to schedule the meeting, and the Social Services Director acknowledged the lapse. The facility's policies emphasize the importance of involving residents in care planning, which was not adhered to in this case.
A resident with multiple diagnoses, including Stage 4 pressure injuries and functional quadriplegia, did not receive scheduled showers or bed baths as required, leading to inadequate hygiene care. Facility records and staff interviews confirmed the absence of skin inspection sheets and failure to provide necessary care, despite policies outlining the need for regular bathing and skin inspections to prevent further skin breakdown.
Late Medication Administration and Controlled Drug Count Errors
Penalty
Summary
Medications were not administered within the facility’s required one-hour window before or after the scheduled time for 18 of 30 residents on Station A during the morning medication pass. During concurrent observation, an LVN was administering medications to one resident at 9:59 a.m. and stated that 13 additional residents still had 9:00 a.m. medications due, plus one resident with a 10:00 a.m. medication. The LVN stated he had a two-hour timeframe to administer medications to 30 residents and acknowledged that medications scheduled for 9:00 a.m. were considered late if given after 10:00 a.m. The RN supervisor stated the LVN should have asked for assistance when running late, and the DON stated medications should be administered within one hour before or after the scheduled time. One resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, seizures, gastrostomy dependence, and essential hypertension received multiple scheduled medications through the g-tube after the allowable time window. The resident’s medication pass included amlodipine, aspirin, vitamin D, docusate sodium, ezetimibe, ferrous sulfate, lactulose, levetiracetam, losartan, artificial tears, vitamin C, chlorhexidine, and Prostat. The LVN stated the g-tube became clogged during administration and that he had to replace the valve before resuming. The medication administration record showed several medications documented with times later than the actual administration, and the LVN later stated the medications were administered more than one hour late. Controlled medication documentation was also inaccurate for another resident’s pregabalin. During review of the medication cart, the bubble pack count did not match the controlled drug record, with one count showing 21 capsules remaining and the record showing 22, and another showing 21 capsules remaining while the record showed 20. The LVN stated he removed pregabalin from the AM bubble pack but documented it on the PM controlled drug count sheet. He also stated he was supposed to check the controlled medication book before removing the medication and document it on the controlled medication count sheet as soon as it was removed, then complete the eMAR entry after administration. The DON stated controlled medication documentation should be accurate and timely and that the nurse should document the medication on the controlled medication count sheet as soon as it is removed from the medication card.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label multiple medications according to manufacturer instructions and its own policies across four medication carts and one medication room refrigerator. During observation and interview, gabapentin oral solution for two residents was found in medication carts instead of the refrigerator, even though the pharmacy labels and manufacturer labeling required refrigeration. One resident’s bottle had an open date and only about one-fourth of the volume remaining, and another resident’s bottle had less than one-fourth remaining; staff stated the medication had been removed from the refrigerator for dosing and should have been returned, and one nurse stated it may have been in the cart for several hours. In Station C Medication Cart 3, insulin storage and labeling were not maintained for two residents. One resident’s insulin lispro prefilled pen was found opened and expired, with the open date and expiration date showing it should have been discarded, and the MAR indicated the resident potentially received the expired insulin multiple times. The same cart contained a Lantus Solostar pen for another resident with no open date documented, and that resident’s MAR also showed potential administration of an expired Lantus Solostar pen multiple times. The nurse stated the expired insulin should have been removed and that it might not be safe or effective. In Station A Medication Cart 1 and the Station A Medication Room Refrigerator, a resident’s morphine sulfate oral solution was found stored in the refrigerator even though the manufacturer labeling required controlled room temperature storage. The nurse stated the medication was supposed to be stored at room temperature and that refrigeration was against the manufacturer’s requirements. The DON stated gabapentin could become less potent if improperly stored, insulin should be discarded 28 days after opening, and morphine stored in the refrigerator could become too thick and not be a comfortable consistency to administer. The facility policies reviewed stated medications must be stored under proper temperature conditions, expired medications must be removed, and insulin multi-dose containers must be dated when opened.
Infection Control Lapses With Equipment Cleaning, IV Removal, Hand Hygiene, and Catheter Bag Placement
Penalty
Summary
The facility failed to follow infection control measures for five sampled residents. Two residents, Resident 4 and Resident 37, had padded side rails wrapped with porous foam and secured with electrical tape. During observation, the foam-wrapped side rails were seen in both rooms, and housekeeping staff stated the side rails were cleaned with 730 solution and Super Sani-Cloth. The Infection Preventionist reviewed the manufacturer guidelines and stated both products were designed for nonporous surfaces, and that using them on porous foam was not appropriate because the foam could not be cleaned properly and could break down. Resident 39 had a peripheral IV catheter in the right hand after receiving Ertapenem for UTI. The antibiotic course was completed, but the PIV remained in place when the resident was observed on the unit, and the resident stated she was not receiving any medication or fluids that required the line. The catheter was later removed the next day. The RN supervisor stated the PIV should have been removed after the last dose of antibiotic and acknowledged it had been left in place after it was no longer needed. The DON also stated the peripheral IV catheter should be removed when no longer needed. Resident 148 was dependent on staff for multiple activities of daily living and had no decision-making capacity. During observation, CNA 7 entered the resident’s room and put on gloves without performing hand hygiene. The CNA stated he forgot to practice hand hygiene before putting on gloves. In addition, Resident 44 had a suprapubic catheter, and the drainage bag was observed on the floor during two separate observations. CNA 8 and LVN 4 both acknowledged the bag was on the floor and stated it should be secured on the bed frame. The DON stated the drainage bag should always be kept off the floor and below the bladder, and that the catheter tubing should be secured with a leg anchor when ordered.
Unclear indication and diagnosis for Seroquel use
Penalty
Summary
The facility failed to ensure that Resident 10’s Seroquel (quetiapine) was prescribed and administered with an appropriate clinical indication and diagnosis. Resident 10 was admitted with diagnoses including unspecified dementia without behavioral disturbance, generalized anxiety disorder, and recurrent major depressive disorder. A psychiatry note dated 7/1/2025 documented that the resident had been on trazodone for insomnia, had been agitated and restless after admission, and had no other major behavioral issues reported, with diagnoses listed as alcohol use disorder, alcohol-induced sleep disorder, and unspecified insomnia disorder. Medication regimen reviews later identified concerns about the Seroquel order and the underlying diagnosis. On 1/22/2026, the consultant pharmacist noted Seroquel 25 mg twice daily for agitation and wrote to clarify the diagnosis and appropriate behavior, but no follow-through notes were documented. On 2/27/2026, the pharmacist noted Seroquel 50 mg twice daily for agitation manifested by trying to jump out of bed and again requested follow-up to clarify the underlying diagnosis; the follow-through documented dementia with behavioral disturbances. On 3/29/2026, the pharmacist again noted Seroquel 50 mg twice daily for mood instability manifested by agitated outburst and requested clarification of the underlying diagnosis, with no follow-through notes documented. A physician note from 3/23/2026 stated that Seroquel and PRN Ativan had been added, that the resident remained restless but less agitated, and that the diagnosis was ETOH use disorder, unspecified sleep disorder, and unspecified mood disorder, with the plan to change the indication for Seroquel to mood instability manifested by agitated outbursts. The MDS dated 3/24/2026 listed dementia, anxiety disorder, and depression, but did not indicate a cognition score. The MAR showed Seroquel 25 mg administered 51 times in February 2026, and Seroquel 50 mg administered 48 times in March 2026 and 44 times from 4/1/2026 through 4/22/2026. During interview, an LVN stated the resident was on Seroquel for angry outbursts, agitation, wandering, and screaming, and said the resident should have been evaluated by a psychiatrist for his illnesses; the DON stated the psychiatric consult had not been uploaded into the electronic record and that the facility routinely saw residents by psychiatry at least quarterly.
Inaccurate MDS Coding of Oral and Dental Status
Penalty
Summary
The facility failed to accurately assess the oral and dental status on the MDS for one resident. Resident 26 was admitted with diagnoses including DM, schizoaffective disorder, depression, and HTN. The dietary assessment documented the resident as edentulous and having no difficulty chewing or swallowing, but the MDS dated 3/7/2026 indicated the resident had natural teeth. The MDS also documented moderately impaired cognitive skills and that the resident required setup or clean-up assistance with oral hygiene, dressing, and personal hygiene. The resident’s care plan titled Dental Care, initiated on 4/23/2026, identified the resident as edentulous and at risk for inadequate nutrition and alteration in comfort, with interventions including notifying the physician about pain issues and monitoring food intake, appetite, and weight. During observation on 4/21/2026, Resident 26 had no natural teeth and stated she did not like dentures because they hurt and wanted dental implants. The MDS nurse stated the MDS assessment was not coded correctly regarding the resident’s oral and dental status, and the DON stated that an accurate assessment is needed to ensure the appropriate plan of care is implemented.
Failure to Complete Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure timely follow-up and coordination of a required PASRR Level II evaluation for Resident 14 after the resident’s PASRR Level I screening identified a need for further evaluation for Serious Mental Illness (SMI). Resident 14 was initially admitted and later readmitted to the facility, and the admission record listed diagnoses of paranoid schizoaffective disorder, major depressive disorder, and anxiety disorder. The resident’s MDS dated 1/26/2026 indicated moderate cognitive impairment and need for maximal assistance with eating, oral hygiene, and upper body dressing. During record review and interview, the PASRR Level I screening dated 05/02/2025 showed that a Level II mental health evaluation was required. A Notice of Evaluation for Level II screening completion dated 05/07/2025 stated the Level II assessment was not completed because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level II screening, and the case was subsequently closed without completion of the required evaluation. MDSN 1 stated the facility failed to follow up because no staff member took ownership of the task and the process was overlooked, and the DON stated residents identified through PASRR Level I screening as requiring Level II evaluation must receive timely follow-up.
Missing PASRR-Related Care Plan for Resident with Mental Health Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident 14 after the resident was identified through PASRR Level I screening as requiring a Level II evaluation for mental illness. Resident 14 was admitted and later readmitted to the facility with diagnoses including paranoid schizoaffective disorder, major depressive disorder, and anxiety disorder. The resident’s MDS dated 1/26/2026 indicated moderate cognitive impairment and need for maximal assistance with eating, oral hygiene, and upper body dressing. During a concurrent interview and record review on 04/24/2026, the MDS nurse confirmed the records showed Resident 14 screened positive on PASRR Level I and required a Level II evaluation, but the EHR contained no evidence of an individualized, interdisciplinary care plan addressing the resident’s mental health or specialized service needs. The MDS nurse stated she believed the care plan had been completed, but none could be found in the EHR. The DON stated the care plan was missing because the facility failed to complete the PASRR Level II and that the process lacked clear staff assignment, which led to the follow-up being missed.
Failure to Provide Required Two-Person Assistance During Incontinent Care
Penalty
Summary
The facility failed to ensure that one sampled resident received safe and adequate assistance with activities of daily living when incontinent care was provided by only one staff member instead of the required two-person assistance. Resident 37 was admitted and readmitted to the facility with diagnoses including chronic respiratory failure, encephalopathy, and sepsis. The resident's H&P indicated the resident did not have the ability to understand and make decisions and had a tracheostomy, G-tube, and foley catheter. The MDS indicated the resident's cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, showering, personal hygiene, and rolling left and right. The resident's Task List Report indicated two- to three-person assist as needed during turning to maintain spine alignment. During observation, a CNA provided incontinent care alone while supporting the resident's left side and buttock with one hand and cleaning, changing the brief, and replacing linens with the other hand for about 10 minutes. The resident was observed coughing intermittently during the care. The CNA stated the resident was typically provided incontinent care by two staff members, but the other staff member was busy, so she performed the care alone. The RNS and DON both stated the resident required at least two-person assistance for turning and incontinent care, and the facility's policies indicated staff should use sufficient assistance as reflected in the resident's plan of care and provide care according to the assessed level.
Failure to Provide Oral Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure oral hygiene care was provided for a resident who was dependent on staff for oral care. Resident 184 was admitted with diagnoses including dysphagia, emphysema, and muscle wasting and atrophy. The MDS dated 04/22/2026 indicated severe cognitive impairment and dependence in oral hygiene, toileting, and shower/bath, with substantial to maximal assistance needed for dressing. During a concurrent observation and interview on 04/21/2026 at 10:50 a.m., Resident 184 was found lying in bed with her mouth full of a brown, sticky substance coating the roof of her mouth, tongue, teeth, and lips. The resident stated her mouth had not been cleaned for a while and she did not know what was inside her mouth. RNS 3 observed the substance, stated it appeared to be brown crust, and began mouth care with a swab while waiting for the assigned CNA. CNA 4 stated she had Resident 184 on assignment on 04/20/2026 and again on the day of the observation, but did not perform oral care because the resident had a mouth sore and she was unsure whether the CNA or a licensed nurse should clean the resident's mouth. The DON stated CNAs were expected to understand the importance of oral care and seek clarification when unsure. The facility policy stated residents unable to perform ADLs independently would receive the service necessary to maintain personal and oral hygiene.
Failure to Ensure Fall Prevention Measures and Proper Meal Positioning
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for Resident 163 by not ensuring staff were informed of the resident’s fall-prevention interventions and by not ensuring the bed pad alarm was functioning when the resident was found on the floor. Resident 163 was admitted with diagnoses including right below-knee amputation, cerebral infarction, difficulty walking, metabolic encephalopathy, and diabetes mellitus. The resident’s H&P noted fluctuating capacity to understand and make decisions, and the MDS indicated moderately impaired cognitive skills, partial/moderate assistance with transfers, substantial/maximal assistance with toileting hygiene and bathing, and a fall since admission. The care plan identified poor safety awareness, noncompliance with safety precautions, attempts to get out of bed unassisted, and interventions including bilateral landing pads, a bed alarm, a wheelchair alarm, and encouragement to use the call light. On 4/21/2026, Resident 163 was found sitting on the floor in the room, and the incident was documented as of unknown nature. During observation, the resident was seen sitting on the right side of the bed and then scooting toward the doorway. No audible alarm was heard from the room, and two staff members walked past without noticing the resident on the floor. CNA 3 later pointed out the resident on the floor to another staff member, which prompted staff to enter the room. At the time of concurrent observation and interview, a landing pad and bed pad alarm were present, but the QAN stated the bed pad alarm was not functioning and worked by pressure. The CSM stated the alarm was not working and would be replaced, and also stated he did not perform routine checks to ensure bed pad alarms were functioning properly. During interviews, CNA 2 stated she did not know Resident 163 was at high risk for falls and was not familiar with the resident. She stated staff are informed during morning huddle if a resident is identified as high fall risk, but the facility did not hold a morning huddle that day. CNA 2 also stated she did not check the bed pad alarm because the resident was asleep. RNS 3 stated Resident 163 could not walk independently and was at high risk for falls due to the amputated leg and behavioral issues, and that CNAs and licensed nurses were responsible for ensuring bed pad alarms were functioning properly. The DON stated fall-prevention measures cannot be implemented effectively if staff are unable to identify residents who are at high risk for falls. The facility also failed to ensure Resident 188 was repositioned upright before meal consumption. Resident 188’s MDS indicated intact cognitive skills for daily decision making, substantial/maximal assistance with sit-to-lying and lying-to-sitting, and supervision or touching assistance with eating and oral hygiene. During lunchtime observation, Resident 188 was in bed in a slouched position, sliding downward, and unable to safely access the meal tray. Resident 188 stated CNA 6 delivered the meal tray without repositioning her into an upright position. CNA 6 stated she stepped out to find help to reposition the resident for the meal but became busy passing meal trays and forgot to return. CNA 6 stated failing to reposition the resident could cause choking and aspiration. RNS 3 stated residents were required to be properly positioned upright during mealtimes, and the DON stated staff must properly position all residents during mealtimes to reduce the risk of aspiration and choking.
Improper Foley Drainage Bag Positioning
Penalty
Summary
Proper urinary catheter care was not maintained for one resident with an indwelling Foley catheter. Resident 37 was admitted with diagnoses including chronic respiratory failure, benign prostatic hyperplasia, and urinary retention. The resident's H&P stated he did not have the ability to understand and make decisions, and the MDS indicated his cognitive skills for daily decision making were severely impaired. He was dependent on staff for oral hygiene, toileting hygiene, showering, personal hygiene, and rolling left and right. The resident's care plan for an indwelling Foley catheter included an intervention for staff to keep the drainage bag below bladder level and change the bag as needed. During a concurrent observation and interview, a CNA was observed providing personal care for about 10 minutes while the Foley drainage bag remained on top of the bed and was filled with urine. The CNA stated she placed the bag on top of the bed during personal care to prevent accidental pulling of the catheter and drainage bag. The DON stated the drainage bag should be maintained below the level of the bladder to prevent backflow of urine into the resident's bladder and reduce the risk of UTI. The facility policy also stated staff must always keep the drainage bag below bladder level.
Failure to Provide Adequate Hydration to a Visually Impaired Resident
Penalty
Summary
The facility failed to ensure adequate hydration for one sampled resident who was visually impaired and required substantial to maximal assistance with eating and oral hygiene. The resident had diagnoses including dysphagia, glaucoma with visual loss in both eyes, and diabetes mellitus type 2. The resident’s care plan identified a goal of maintaining adequate hydration, and laboratory testing showed elevated BUN and creatinine levels on 3/16/2026. On observation, the resident was found lying in bed with a sign above the head of the bed stating, "I'm blind please give me water." The bedside table was positioned at the foot of the bed, the water pitcher was empty, and no alternate fluids were available. Additional observations later the same day and the next day again showed the bedside table not within reach and the water pitcher empty. The resident had no means to independently access fluids. The resident representative stated the facility did not provide water throughout the day and reported that the bedside table was often not within reach, the pitcher was empty, and no cup was available. The representative also stated the resident had recently required IV fluids for dehydration after becoming severely dizzy. Staff interviews confirmed the resident needed the bedside table and fluids within reach and required additional assistance because of visual loss. The DON stated residents at risk for dehydration should have fluids offered routinely and that dependent residents, including those with visual impairments, require active assistance and prompting to ensure adequate hydration.
Expired Tube Feeding Formula Left Connected to Resident
Penalty
Summary
The facility failed to provide necessary care and services for one of two sampled residents receiving enteral feeding. Resident 3 had diagnoses including anoxic brain damage, dysphagia, gastrostomy, and cerebral aneurysm, and the admission history and physical indicated the resident did not have the capacity to understand and make decisions. The order summary showed Isosource 1.5 was ordered at 75 ml per hour for 10 hours via gastrostomy tube, with the feeding to start at 8:00 p.m. and stop at 6:00 a.m. During observation, Resident 3 was lying in bed with an enteral feeding pump next to the bed, and the tube feeding bag was labeled and dated at 9:00 p.m. while the pump was off but still connected to the resident. During interview and record review, staff stated the tube feeding formula was only good for 24 hours once the bag was opened and spiked, and that the bag observed was already expired. Staff also stated the bag should have been discarded and that charge nurses each shift should check the tube feeding bag for expiration. The facility policy required staff caring for residents with enteral feedings to ensure accurate labeling and dating of each feeding bag or formula container, with an expiration date/time per manufacturer or facility protocol.
IV Site Not Properly Labeled or Monitored During Vancomycin Infusion
Penalty
Summary
The facility failed to ensure safe, appropriate administration and monitoring of IV fluids for one sampled resident who was receiving IV Vancomycin for ventilator-associated pneumonia. The resident had multiple sclerosis, respiratory failure, sepsis, and severely impaired cognition, and was dependent on staff for personal care. The order required Vancomycin 1 gram IV every 12 hours and daily and nightly monitoring of the peripheral IV site for signs of infection or infiltration. On observation, the resident was receiving Vancomycin through a left hand IV access, and the IV site dressing did not have the insertion date, time, or staff initials. The RN supervisor stated she had started the infusion about one hour earlier and, on reassessment, found the IV had infiltrated with redness and swelling. The DON stated staff must label the IV dressing with the insertion date, time, and initials, and that the IV site should be reassessed after initiation of IV medication. Facility policies also required labeling of the IV dressing and ongoing assessment for infiltration, phlebitis, infection, redness, swelling, pain, warmth, leakage, and other signs of IV complications.
Oxygen Flow Rate and Nasal Cannula Dating Not Followed
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for Resident 150. The resident was admitted and readmitted with diagnoses including hydrocephalus, chronic respiratory failure, and intracranial hemorrhage. The H&P stated the resident did not have the ability to understand and make decisions, and the MDS indicated severe cognitive impairment and dependence for oral hygiene, toileting hygiene, showering, and personal hygiene. The physician's orders directed staff to administer oxygen at 2 L/min via NC as needed to keep oxygen saturation above 92% and to change the NC every Saturday night shift. During observation, Resident 150 was receiving oxygen through a NC, but the tubing had no date label showing when it was last changed. The RNS confirmed the oxygen flow rate was set at 3 L/min and that the NC lacked the required date label. The DON stated staff were expected to date NC tubing to promote infection prevention and ensure oxygen was administered in accordance with the physician's order. Facility policy required oxygen flow rate to match the physician order and required oxygen tubing to be dated when initiated or replaced.
Failure to Enforce Ordered Fluid Restriction
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis-related care for a resident with ESRD, CHF, dependence on renal dialysis, and type 2 DM who had a physician order for a 1000 ml/24-hour fluid restriction. The resident’s care plan identified fluid restriction as ordered, and the order summary specified the daily limit and how fluids were to be distributed across nursing and dietary shifts. The resident also had documented edema on the skin observation tool and mild cognitive impairment noted in the history and physical. On observation, the resident was lying in bed with oxygen in use and had bilateral lower and upper extremity edema. Multiple food and beverage items were present at the bedside, including soda, chips, pastries, and three Gatorades. A CNA stated the resident was on fluid restriction but did not know the current allowance, did not monitor or total fluid intake, did not document intake, and had not received training on monitoring or documenting fluid intake. The CNA also stated fluids were left at the bedside and were not controlled or restricted, and that she had not been informed of the restriction through shift report or the care plan. Record review showed the resident’s April MAR documented multiple days when total fluid intake exceeded the ordered 1000 ml/24-hour limit, including totals of 1500 ml, 1040 ml, 1140 ml, 1620 ml, 1500 ml, 1500 ml, 1330 ml, 1280 ml, and 2400 ml. An LVN stated CNAs were responsible for reporting intake, license nurses calculated and documented total daily intake, and signs of fluid overload included edema, crackles, shortness of breath, and weight gain. The LVN acknowledged the resident had bilateral edema, crackles, and weight gain, and confirmed these findings had not been reported to the physician. The DON stated fluid restrictions were to be implemented into the care plan, dietary plan, and nursing documentation with intake tracking, and that staff should notify the physician if noncompliance or failure to follow restrictions was identified.
Failure to Clarify Diagnosis Supporting Seroquel Use
Penalty
Summary
The facility failed to act on consultant pharmacist recommendations from multiple monthly medication regimen reviews for Resident 10 regarding clarification of the diagnosis supporting Seroquel (quetiapine) use. The pharmacist repeatedly noted the need to clarify the underlying diagnosis and appropriate behavior for the medication, including on 1/29/2026, 2/27/2026, and 3/29/2026, but the record did not show follow-through documentation for the first and third reviews. The facility policy required identified irregularities to be reported to the attending physician and DON with prompt follow-up and resolution, and required psychotropic medications to have a documented clinical indication/diagnosis. Resident 10’s record showed diagnoses including unspecified dementia without behavioral disturbance, generalized anxiety disorder, and recurrent major depressive disorder. A psychiatry note dated 7/1/2025 documented agitation and restlessness after admission, with diagnoses of alcohol use disorder, alcohol-induced sleep disorder, and unspecified insomnia disorder. The medication regimen review on 2/27/2026 noted Seroquel 50 mg twice daily for agitation manifested by trying to jump out of bed and requested follow-up with the doctor to clarify the underlying diagnosis and monitor for behaviors and side effects; the follow-through documented dementia with behavioral disturbances. Later documentation showed the physician changed the indication for Seroquel to mood instability manifested by agitated outbursts, while the MDS dated 3/24/2026 listed diagnoses of non-Alzheimer’s dementia, anxiety disorder, and depression but did not indicate a cognition score. The 3/29/2026 pharmacist review again requested clarification of the underlying diagnosis, and no follow-through notes were documented. During interview, the LVN stated Resident 10 was on Seroquel for angry outbursts, agitation, wandering, and screaming, and said the resident should have been evaluated by a psychiatrist. The DON stated the consultant pharmacist recommendations were reviewed and attempted to be addressed, but also stated the psychiatric consult had not been uploaded into the electronic record and would need to be located.
Failure to Monitor Opioid Side Effects
Penalty
Summary
The facility failed to ensure that one sampled resident, who had diagnoses including chronic pain, heart failure, and difficulty walking, was monitored for side effects and adverse reactions related to opioid use. The resident was receiving Oxycodone 15 mg by mouth every six hours and 7.5 mg at bedtime, along with Morphine Sulfate 15 mg by mouth every 12 hours for chronic pain. The resident’s care plan identified the resident as being at risk for pain and on pain medication therapy, with interventions to monitor, document, and report adverse reactions to analgesic therapy. During record review and interview, the Medication Administration Record and Order Summary were reviewed with the RNS, who stated there was no monitoring documented for side effects related to Oxycodone and Morphine Sulfate. The RNS identified depressed respiratory rate, low blood pressure, cold and clammy skin, and sedation as known side effects of these medications and stated licensed nurses should monitor residents for opioid-related side effects. The DON also stated that central nervous system depression and respiratory depression are known side effects of Morphine and Oxycodone, and that the resident could experience respiratory depression if staff did not monitor for these side effects.
Medication Pass Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent during medication pass, with a reported error rate of 6.67 percent involving two sampled residents. One resident had a history of hemiplegia, hemiparesis following cerebral infarction, gastrostomy status, seizures, and hypertension, and was dependent on staff for activities of daily living. During observation, an LVN prepared multiple medications and a protein supplement for administration via g-tube, including levetiracetam (Keppra) ordered every 12 hours for seizure disorder. The resident’s levetiracetam was documented on the MAR as given at 10:14 a.m., but the medication pass was observed at 11:22 a.m., and the MAR later reflected a documented time of 11:27 a.m. The facility’s policy stated routine medications should be administered within one hour before or after the scheduled time, and anti-seizure medications were identified as time-critical. A review of the resident’s medication audit showed 15 instances between 4/1/2026 and 4/22/2026 in which levetiracetam scheduled for 9:00 a.m. was administered late, including times after 10:15 a.m. and one instance at 1:20 p.m. During interview, the LVN stated the medications, including Keppra, were administered late by over one hour because they should have been given within the one-hour window before or after the scheduled time. The DON stated that if the surveyor began observing at 9:59 a.m., the 9:00 a.m. medications should have been completed by 10:00 a.m., and that late administration placed the resident at risk for seizures and hospitalization. The second resident had diagnoses including hemiplegia and hemiparesis following intracerebral hemorrhage, dysphagia, gastrostomy status, and bacterial infections, and was dependent on staff for multiple ADLs. The physician ordered the g-tube to be flushed with 30 mL of water before and after medication administration, and psyllium husk powder was ordered via g-tube every 8 hours. During observation, an LVN administered psyllium husk solution via g-tube but did not flush the tube with water before or after the dose. The LVN stated this was an error and acknowledged that flushing was important to prevent clogging of the g-tube and syringe. The DON also stated the nurse should have flushed the g-tube with 30 mL of water before and after administering psyllium husk in accordance with the physician’s order.
Late Administration of Time-Critical Anti-Seizure Medication
Penalty
Summary
Resident 128, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction, gastrostomy dependence, seizures, and hypertension, was observed during medication administration receiving 13 medications, including Keppra (levetiracetam) 100 mg/mL oral solution via g-tube. The resident’s MDS indicated the resident was rarely or never understood and was dependent on staff for multiple ADLs. The physician order for levetiracetam was 500 mg/5 mL via g-tube every 12 hours for seizure disorder, with monitoring for seizure activity. During the observation, the LVN administered the resident’s medications later than the scheduled time, and the MAR documentation did not match the observed administration time. The MAR showed levetiracetam administered at 10:14 a.m. and also documented at 11:27 a.m., while the medication was observed being given at 11:22 a.m. The facility’s audit report showed 15 instances between 4/1/2026 and 4/22/2026 when levetiracetam scheduled for 9:00 a.m. was administered after 10:15 a.m., including occasions when it was given as late as 1:20 p.m. The facility’s policy required routine medications to be given within one hour before or after the scheduled time and identified anti-seizure medications as time-critical. In interviews, the RNS stated medications should be administered within one hour before or after the scheduled time and that the LVN should have requested assistance when running late. The LVN stated the resident’s medications, including Keppra, were administered more than one hour late and acknowledged the delay could reduce the effectiveness of Keppra and place the resident at risk for seizures and possible hospitalization.
Uncovered facial hair during kitchen food preparation
Penalty
Summary
The facility failed to practice standard hygienic practices in the kitchen when two staff members did not wear beard restraints during food preparation. During an observation in the kitchen, the AM Cook was seen standing at the food preparation table with an uncovered beard approximately two to three inches in length around the chin while seasoning chicken on a baking sheet and then chopping fresh zucchini for the lunch meal without a beard net or restraint. At the same time, the Assistant Dietary Supervisor, who had a beard spanning the jawline and sideburns approximately 0.5-1.0 inches in length, was assisting in the kitchen preparation area without wearing a beard net or restraint. During interview, the Dietary Supervisor stated that beard restraints were worn during service but not during prep. Beard restraints were not observed at the kitchen entrance where hair nets were routinely provided. When asked about their location, the Dietary Supervisor retrieved a cardboard box from under a desk in her office that contained a clear plastic bag filled with beard nets. Facility policy stated that all employees must wear hair restraints to prevent contamination of food, equipment, or utensils, and that beards, sideburns, and mustaches that are not closely cropped and neatly trimmed shall be covered. The report also cited FDA Food Code section 2-402.11 and 21 CFR 11.10(b)(6) regarding the use of hair coverings and beard covers.
Incomplete and inaccurate weight documentation with no follow-up for a large weight loss
Penalty
Summary
The facility failed to ensure clinical weight records were complete and accurate for one resident whose record showed a weight of 200 lbs on 2/11/2026, 199 lbs on 03/06/2026, and 97.8 lbs on 03/30/2026, reflecting a documented 50.85% loss from 3/6/2026 to 3/30/2026. The resident’s admission record showed diagnoses including chronic respiratory failure, dependence on a ventilator, and atrial fibrillation. The resident’s MDS dated 2/9/2026 indicated cognitive status was intact and that the resident was dependent on staff for oral hygiene, toileting hygiene, showering, and personal hygiene. During interview and record review, the RNS stated there was no documentation regarding the weight loss recorded on 3/30/2026, no recheck weight was obtained, and no follow-up was completed. The RNS stated the weight change represented a change of condition, but no COC assessment was completed, the attending physician was not notified, and no follow-up was initiated with the RD. The RNS also stated sufficient time had elapsed to correct the weight if it had been a documentation error. The DON stated staff should have reassessed the resident’s weight immediately to verify accuracy, and if confirmed, a COC assessment should have been completed and interventions initiated promptly.
Failure to Involve Conservator and IDT in High-Risk Resident’s Discharge to RCC
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate discharge planning for a resident who was a Regional Center client with schizoaffective disorder bipolar type, unspecified psychosis, anxiety disorder, seizures, anemia, and severe cognitive impairment. The resident’s face sheet identified a conservator as the responsible party, and the MDS dated 11/19/2025 documented severely impaired cognitive skills for daily decision-making and dependence on staff for ADLs, with no ability to ambulate independently. The resident had documented high elopement risk and fall risk, including balance problems and decreased muscular coordination. Social Services documentation from 11/10/2025 indicated the resident came from a homeless environment and might need additional help once discharged home with the support of the conservator. An IDT conference on 11/14/2025 included the conservator by phone, but no discharge planning was discussed at that time, and the notes indicated the bed hold policy and discharge plan would be reviewed with the responsible party/conservator. On 1/28/2026, a physician’s order was obtained to discharge the resident to a recuperative care center (RCC). A progress note timed at 1:20 p.m. on that date documented that the resident was discharged and picked up by EMT personnel, with standard safety checks such as identity verification, confirmation of transfer destination, attachment of transfer documents, and securing the resident on a gurney. The same note indicated that a voicemail was sent to the conservator notifying them of the transfer, but there was no documentation of prior discussion, involvement, or consent from the conservator regarding the discharge plan or the choice of RCC. Social Services Staff stated that the resident was conserved under a Public Guardian and that the facility did not discuss the discharge planning or transfer to the RCC with the conservator, and that no IDT meeting was held related to the discharge plan prior to discharge. The DON stated that she and Social Services decided to transfer the resident to the RCC because the resident did not meet skilled criteria and needed a lower level of care where medications would be managed, and acknowledged that the conservator was not involved in the discharge planning or discharge and that there was no IDT meeting conducted for this discharge. The facility also failed to ensure adequate communication and clinical handoff to the receiving RCC. LVN 1 described the expected discharge process as including obtaining a physician’s order, performing a skin assessment, notifying the family or conservator, preparing discharge paperwork, printing the face sheet and medication summary, and contacting the receiving facility. LVN 1 stated these steps were not fully completed for this resident’s discharge, that he was unable to communicate with the conservator or the receiving facility, did not communicate with a receiving nurse, did not perform medication reconciliation, and did not endorse the resident’s medical history to the receiving facility. He reported that paperwork was handed to EMT personnel at the time of discharge and that he failed to verify the type of setting at the RCC to ensure it could meet the resident’s needs. Subsequently, EMS and hospital records documented that the resident was found wandering in the street in the early morning hours, not alert or oriented, with insect eggs on her clothes and hands, and was transported to a general acute care hospital where she was admitted with acute psychosis and altered mental status. Interviews with the conservator, CNA staff, and review of the facility’s discharge planning policy further confirmed that the resident’s discharge occurred without the required involvement of the conservator, without an IDT discharge planning process, and without appropriate clinical communication to the receiving RCC. The facility’s own policy on discharge planning required the Social Services Director or designee to be involved in discharge planning to ensure a safe discharge and successful transition to the next level of care or return home, working with the IDT, physician, resident, and resident’s representative. The policy specified that discharge planning services and any changes to the discharge plan were to be discussed with the resident and, if indicated, the resident’s representative, and documented in the medical record. In this case, interviews and record review showed that the conservator was not involved in selecting the RCC or consenting to the discharge, that no IDT meeting was held to assess the resident’s cognitive, medical, physical, and psychosocial needs prior to discharge to a lower level of care, and that the RCC was not properly notified of the resident’s diagnoses, medications, history of wandering, and risk for falls and seizures prior to transfer. These actions and omissions constituted the deficient practice cited under F-627 for failure to ensure a safe and appropriate discharge for this resident.
Removal Plan
- The DON/designee conducted an immediate clinical review of Resident 1’s status in collaboration with the GACH, including medication reconciliation and continuity of care.
- The IDT (Social Service, DOR, DON, ADON/QA Nurse, DSD, MDS Nurse) met to review root cause analysis and ensure discharge planning criteria/process compliance.
- The IDT (SSD, DON, ADON) conducted a facility-wide review of discharges, focusing on level of care determination, IDT involvement, legal representative notification/consent, safe discharge destination, and medication reconciliation/continuity.
- Require licensed nursing staff to notify the SSD of all resident discharges and have discharge information communicated to the SSD and reviewed during the weekly discharge planning meeting (including assessment of cognitive impairment, elopement risk, behavioral symptoms, conservatorship/legal representative involvement, and discharge planning), with variances corrected immediately.
- Require DON or designee to provide final authorization prior to discharge.
- During weekends/when SSD and DON are not physically present, require the Nursing Supervisor to review discharge documentation, confirm completion of required steps, and notify the SSD and DON for follow-up review.
- Implement a Hard Stop Discharge Protocol using a standardized interdisciplinary discharge checklist; no resident may be discharged until all checklist steps are completed.
- Require final approval by the Administrator or DON for all planned discharges to lower levels of care (including RCFE, ALF, ILF, and recuperative care) upon completion of the Hard Stop checklist.
- Require discharge planning to begin at baseline admission and be reviewed at least 30 days prior to projected discharge, again 7 days prior, and prior to the day of discharge.
- Assign QA Nurse responsibility for resident assessment and participation in the discharge process.
- Assign IDT (SSD, DOR, DON, DSS, QA) responsibility for reviewing discharge planning.
- Assign DON/QA/DON designee responsibility for reviewing clinical readiness and safety prior to discharge.
- Require licensed nursing staff to provide a complete handoff to the receiving provider/facility at discharge (clinical status, medications, care needs, follow-up requirements) and document the handoff in the medical record.
- Require SSD and licensed nursing staff to notify the resident’s guardian/responsible party regarding discharge planning, provide discharge destination options, and document preferences/consent in the medical record.
- Assign SSD responsibility for all discharge notices and documentation (notify resident/guardian/responsible party, document discharge plan and chosen destination, maintain related forms/communications in the medical record, ensure timely completion).
- Require Nursing Supervisor or licensed nursing staff to provide a complete handoff report to the receiving facility at discharge (clinical status, medications, care needs, behavioral considerations, follow-up requirements) and document it in the medical record.
- Require SSD to complete post-discharge follow-up/wellness check within 72 hours to confirm safe arrival, medication/care management, identify concerns, and document follow-up actions.
- Provide in-service training to the DON and Administrator on the Policy of Safe Discharge Planning, including the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety considerations, and compliance monitoring.
- Provide 1:1 in-service and competency validation with the SSD on the Policy of Safe Discharge Planning, including the Hard Stop Discharge Protocol, interdisciplinary responsibilities, resident safety requirements, and documentation expectations.
- Educate all licensed nurses, Social Services staff, and IDT members on CMS discharge requirements, resident rights, safe transitions of care, documentation expectations, legal representative notification, and high-risk discharge criteria; provide training by DON and SSD with attendance logs; include in new hire orientation.
- Audit all resident discharges using the Hard Stop Discharge Checklist (daily for first 2 weeks, weekly for next 4 weeks, then monthly) through QAPI to ensure ongoing compliance.
- Ensure on the day of discharge the licensed nurse provides a complete report/handoff to the receiving facility prior to transfer.
- Have Medical Records review audit findings and report results to DON/ADON/QA team; correct discrepancies timely; report results to the QAPI Committee by DON and SSD.
- Incorporate the discharge process into the facility’s QAPI program, including tracking/trending discharge variances, identifying root causes, implementing corrective actions, and reporting findings to leadership, with a performance goal of 100% compliance.
Failure to Maintain Resident Dignity by Not Covering Foley Catheter Bag
Penalty
Summary
A deficiency was identified when a resident with a Foley catheter was observed seated in a wheelchair in the hallway without a dignity bag covering the catheter bag. The resident confirmed that he did not have or use a dignity bag for his Foley catheter. The resident's medical history included hemiplegia and hemiparesis following a stroke, difficulty walking, anemia, and the use of a Foley catheter as indicated by physician orders and assessment records. The Minimum Data Set showed the resident was able to make himself understood, understand others, and was independent in several activities of daily living, requiring only supervision for personal hygiene. Interviews with facility staff revealed that the CNA was unaware the resident had a Foley catheter and therefore did not cover the catheter bag. The LVN also did not notice the Foley catheter bag during her shift. The Director of Nursing stated that the resident should have had the Foley catheter covered at all times to maintain privacy and dignity, in accordance with facility policy. Review of facility policies confirmed the requirement to treat residents with respect and dignity and to ensure Foley catheters are covered with a dignity bag.
Failure to Initiate IDT Meeting After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) initiated a care conference for a resident following an alleged resident-to-resident altercation. The resident involved had a history of unspecified dementia, generalized anxiety disorder, unspecified psychosis, and hemiplegia/hemiparesis following a cerebral infarction. The Minimum Data Set (MDS) indicated the resident had severely impaired cognitive skills and required supervision or assistance with transfers. After the incident, where the resident allegedly pushed another resident's shoulder multiple times, there was no documented IDT meeting to address the change in condition or to develop a collaborative plan of care. Interviews with facility staff, including the Social Worker, Assistant Administrator, and Director of Nursing, confirmed that no IDT meeting was conducted after the incident, despite facility policy requiring such a meeting following a significant change in a resident's condition. The facility's policy and procedure indicated that the IDT, along with the resident and their representative, should develop and review a comprehensive, person-centered care plan when there is a significant change. The lack of an IDT meeting resulted in a delay in addressing the resident's care needs and implementing necessary interventions.
Failure to Implement Diabetic Management and Insulin Administration Protocols
Penalty
Summary
The facility failed to follow its own policy and procedure for diabetic management and insulin administration for a resident diagnosed with type 2 diabetes mellitus, chronic kidney disease, and quadriplegia. The resident was admitted and readmitted to the facility with orders for diabetes medications, including oral medication and insulin, but there were no consistent orders for blood sugar (BS) monitoring or insulin coverage as indicated by the resident's condition. The care plan for the resident specified monitoring for signs and symptoms of hyperglycemia and regular BS checks, but these interventions were not implemented by the staff. Licensed staff assigned to the resident were not aware of the resident's diabetes diagnosis and did not monitor BS levels or observe for symptoms of hyperglycemia or hypoglycemia. The resident's primary care provider (PCP) was not informed that there were no orders for BS monitoring or insulin coverage, and the PCP was unaware that BS checks were not performed for an extended period. The Medication Administration Record showed that insulin was administered inconsistently, and there were gaps in BS monitoring, particularly from one date to another, during which no BS checks were documented. As a result of these failures, the resident experienced a significant change in condition, presenting with high BS that could not be registered on the glucometer, altered level of consciousness, tachypnea, oxygen desaturation, and hypotension. The resident was transferred to a general acute care hospital, where a critically high blood glucose level was recorded, and the resident was diagnosed with diabetic ketoacidosis with coma, requiring intubation and intensive insulin therapy. Interviews with facility staff, including the RN Supervisor and DON, confirmed that the facility did not implement the care plan or ensure appropriate monitoring and treatment for the resident's diabetes.
Delay in Readmission Following Hospitalization Due to Bed Availability
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on staff for all activities of daily living and had severe cognitive impairment, was promptly readmitted after being stabilized at a general acute care hospital. The resident, who had diagnoses including hemiplegia, hemiparesis, metabolic encephalopathy, and multiple pressure injuries, was transferred to the hospital for evaluation and treatment. Hospital records indicated the resident was ready for discharge back to the facility, but the facility initially reported no bed availability on two separate occasions. Despite the facility's policy stating that residents should be permitted to return to their previous room or the first available bed, the resident remained at the hospital for three additional days after being deemed appropriate for return. The Director of Nursing confirmed that a bed was available on the second attempt, and acknowledged that the resident should have been readmitted at that time, as the facility was the resident's home. This delay in readmission was not in accordance with the facility's stated procedures for bed holds and returns.
Failure to Provide Required Shower Assistance for Resident with Severe Cognitive Impairment
Penalty
Summary
A review of facility records and interviews revealed that a resident with severe cognitive impairment and a history of muscle weakness, difficulty walking, and traumatic brain injury was not assisted with showers at least twice a week as required. The resident's Minimum Data Set (MDS) assessment indicated a need for partial assistance with showering and toileting hygiene, and supervision with oral and personal hygiene. The care plan, initiated in April 2022, specified that the resident required assistance with activities of daily living (ADLs), including a directive to ensure showers two to three times per week. During a review of shower documentation and Point of Care (POC) response history for the month of July, it was confirmed by a registered nurse that the resident did not receive the required number of showers. The Director of Nursing also acknowledged that residents are to be assisted with showers at least twice weekly for personal hygiene. Facility policies reviewed indicated that staff are to assist residents with ADLs and promote cleanliness and comfort, but these were not followed in this instance.
Medication Improperly Stored at Bedside
Penalty
Summary
A tube of Diclofenac Sodium Topical Gel, 1% was found on a resident's nightstand during an observation conducted with an RN. The medication was identified as a used, old medication that was not part of the resident's current physician-ordered medications. Both the RN and the DON confirmed that medications should not be stored at the bedside for resident safety, and that only staff authorized to administer medications should have access to them. The resident involved had diagnoses including hemiplegia and hemiparesis affecting the left side, type 2 diabetes, and low back pain. The resident's cognitive skills for daily decision-making were intact, and they required supervision with eating and partial assistance with personal and oral hygiene. The facility's policy stated that medications must be stored safely, securely, and only accessible to authorized staff, which was not followed in this instance.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and document care plan interventions for a resident identified as high risk for falls. The resident had a history of multiple fractures and repeated falls, and the care plan specifically required visual checks to be performed and documented every shift. However, there was no documentation that these visual checks were completed as required. This omission was confirmed through interviews with nursing staff and the Director of Nursing, who acknowledged that the care plan interventions were not followed or recorded as part of the nursing measures. As a result of the failure to implement and document the required visual checks, the resident experienced an unwitnessed fall that led to multiple pelvic fractures and required hospitalization. The facility's own policies and procedures mandated comprehensive care planning with measurable objectives and documentation of all services provided, but these were not adhered to in this case. The lack of adherence to the care plan and documentation requirements directly contributed to the resident's fall and subsequent injuries.
Failure to Use Mechanical Lift Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident with paraplegia was transferred safely from bed to a shower chair, resulting in a fall and injury. The resident was dependent for transfers and required the use of a mechanical lift as recommended by the Physical Therapy (PT) department. Despite this, two staff members, a Certified Nursing Assistant (CNA) and a Restorative Nursing Assistant (RNA), attempted to transfer the resident manually without the mechanical lift, contrary to the PT recommendation and facility policy. The resident, who had no cognitive impairment and was able to make her own decisions, insisted on being transferred without the mechanical lift because the sling caused her discomfort. The CNA and RNA attempted the transfer manually, realized the resident was too heavy, and assisted her to the floor. During the transfer, the resident experienced pain and, after being assisted to the floor, was later found to have sustained an acute minimally displaced impacted fracture of the distal left femur. Staff interviews confirmed that the mechanical lift should have been used and that the resident's refusal should have been escalated to nursing supervisors. Further review revealed that the facility did not have a care plan intervention specifying the use of a mechanical lift for this resident, despite the PT and Occupational Therapy (OT) recommendations and the resident's high risk for falls. The staff also failed to follow the facility's policies on mechanical lift use and fall prevention, which require all departments to contribute to fall prevention efforts. The lack of a care plan intervention and failure to follow established procedures directly contributed to the resident's injury during the transfer.
Failure to Notify Physician of Resident's Change in Condition After Tracheostomy Tube Change
Penalty
Summary
The facility failed to notify a resident's physician when the resident experienced scant bleeding and significant pain at her tracheostomy stoma site following a tracheostomy tube change. The resident, who had a history of cerebral infarction, tracheotomy status, and acute respiratory failure, was documented as having severe cognitive impairment. Despite a physician's order specifying that the physician should be notified for severe pain, the licensed nurse administered Tylenol Extra Strength for pain rated at eight out of ten but did not contact the physician. Documentation in the Pain Assessment Flow Sheet and Medication Administration Record confirmed the administration of pain medication without physician notification. Interviews with facility staff, including the DON, respiratory therapist, and the nurse involved, revealed that the nurse did not notice the requirement to notify the physician as stated in the pain order. The facility's policy and procedure for change of condition, as well as the job description for licensed nurses, required prompt physician notification for changes in condition. The failure to notify the physician resulted in the physician being unaware of the resident's change in condition and unable to provide further instructions for care.
Failure to Conduct Change in Condition Evaluations for COVID-19 Exposed Residents
Penalty
Summary
The facility failed to complete a Change in Condition (CIC) evaluation for three residents who were exposed to COVID-19. Resident 2, admitted with a diagnosis of Hemophilus influenzae, was cognitively intact and required maximal assistance with daily activities. Despite an order for novel respiratory precautions due to COVID-19 exposure, the facility did not complete a CIC evaluation for Resident 2 in March 2025. Similarly, Resident 3, who was readmitted with pneumonia and influenza and had severely impaired cognitive skills, also did not receive a CIC evaluation following COVID-19 exposure, despite being dependent on assistance for daily activities. Resident 5, admitted with chronic respiratory failure and pneumonia, had moderately impaired cognitive skills and was dependent on assistance for daily activities. Like the other residents, Resident 5 was placed under novel respiratory precautions due to COVID-19 exposure, but the facility failed to conduct a CIC evaluation. Interviews with RN 1 and the Director of Nursing confirmed the absence of CIC evaluations for these residents, which was against the facility's policy requiring comprehensive assessments for significant changes in a resident's condition.
Failure to Use Proper PPE in Precaution Rooms
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) by staff members entering rooms designated for Novel Respiratory Precautions. Specifically, Housekeeping staff and a Certified Nurse Aid entered the rooms of two residents without wearing the required PPE, which includes a gown, eye protection, filtered mask, and gloves. These residents were under novel respiratory precautions due to COVID-19 exposure. The staff members acknowledged the requirement for full PPE but did not comply, citing reasons such as not providing direct patient care or not touching anything in the room. Additionally, a Charge Nurse entered another resident's room, also under novel respiratory precautions, wearing only a mask and not the full PPE as required. The Charge Nurse admitted to the oversight. The facility's policy mandates full PPE for contact and droplet isolation, which was not adhered to in these instances. The Infection Preventionist and Director of Nursing confirmed the necessity of full PPE for entering precaution rooms, aligning with the facility's policy.
Failure to Prevent Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to prevent the development of deep tissue injuries (DTIs) in a resident who was at high risk for pressure injuries. The resident, who was admitted with conditions such as cerebral infarction, chronic respiratory failure, and functional quadriplegia, was dependent on staff for all activities of daily living and was always incontinent of bowel. Despite a care plan and physician orders to turn and reposition the resident every two hours, this was not consistently done, leading to the development of DTIs on the resident's right lateral foot and right buttock. The facility also failed to conduct regular skin assessments as required. The resident's care plan specified that skin assessments should be done daily by CNAs and weekly by licensed nurses, particularly during shower days or bed baths. However, the resident did not receive showers or skin inspections on multiple scheduled days, and there was a lack of documentation indicating that these assessments were performed. This oversight contributed to the resident's skin condition deteriorating without timely intervention. Additionally, the facility did not implement necessary interventions such as the use of Prevalon boots to relieve pressure on the resident's feet until after the DTIs had developed. The lack of adherence to the care plan and physician orders, combined with inadequate skin assessments and failure to apply preventive measures, resulted in the resident developing significant pressure injuries that could have been avoided with proper care and attention.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure timely administration of morning medications in the subacute unit (SAU) for several residents. On two separate days, a number of residents received their morning medications after the designated time window, which was between 8 a.m. and 10 a.m. The delay was attributed to the time-consuming process of administering medications via gastrostomy tubes, which took approximately 30 minutes per resident. With the available staff, the time required to administer medications exceeded the regulatory window, leading to late administration for some residents. The facility also failed to ensure the accuracy of medications upon delivery and before administration. Two residents received Zosyn IV medications that did not match the physician's orders. The facility's pharmacy changed the IV fluid from dextrose to normal saline without notifying the facility or the prescriber. This change was not communicated, and the discrepancy was not identified by the nursing staff before administration. The facility's policy required that medications be administered as prescribed, but this was not adhered to in these cases. Additionally, the facility did not maintain a complete emergency drug usage log. An entry in the log was missing critical details such as the date, time, quantity removed, and the licensed nurse's initials. This lack of documentation could lead to potential medication errors and adverse effects. The facility's policy required a complete record of emergency drug usage, but this was not followed, indicating a lapse in maintaining accurate records.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. Resident 22 and Resident 44 received intravenous antibiotic Zosyn in a manner not consistent with the physician's orders. Resident 22 was supposed to receive Zosyn 3.375 gm in Dextrose 50 ml, but instead received it in 100 ml of normal saline, which was not in accordance with the physician's order. This discrepancy was observed during a medication administration observation and confirmed through interviews and record reviews. Similarly, Resident 44's physician order indicated Zosyn 3.375 gm in Dextrose 50 ml, but the medication label did not match this order. Both residents had conditions that could be adversely affected by incorrect fluid administration, such as heart failure and hypernatremia. Additionally, the facility failed to administer Liothyronine to Resident 361 as per the physician's orders. Resident 361, who had a diagnosis of hypothyroidism, did not receive her thyroid medication on two occasions in March 2025. This was confirmed through interviews and medication reconciliation record reviews. The resident reported not always receiving her thyroid medications in the morning, and the Licensed Vocational Nurse assigned to her on one of the missed days was unsure how the medication was missed. The facility's policy requires medications to be administered in accordance with the orders, including any required time frame. The facility's Medication Administration Policy, which mandates that medications be administered as prescribed, was not adhered to in these cases. The Director of Nursing acknowledged the potential negative effects of administering incorrect IV fluids to residents with certain conditions. The failure to administer medications as ordered increased the risk of adverse health outcomes for the residents involved.
Failure to Provide Adequate ROM and Mobility Services
Penalty
Summary
The facility failed to provide adequate services to residents with limited range of motion (ROM) and mobility, as evidenced by the lack of adherence to physician orders and occupational therapy recommendations. Resident 62, who was admitted with hemiparesis and dementia, did not receive passive range of motion (PROM) exercises for both arms as recommended in the occupational therapy discharge summary. Additionally, active assistive range of motion (AAROM) exercises for both legs were inconsistently documented and not performed as ordered, leading to potential decline in joint mobility and increased pain in the left shoulder. Resident 109, diagnosed with anoxic brain damage and epilepsy, did not receive consistent PROM exercises for both arms and legs, nor were the prescribed splints and orthoses applied regularly. Documentation revealed multiple instances where these interventions were not performed, increasing the risk of contractures and further ROM limitations. The joint mobility screen for Resident 109 was also inaccurately assessed, failing to reflect the true extent of ROM limitations in the shoulders. Resident 112, with a history of cerebral infarction and diabetes, was not provided with the prescribed Omni-cycle exercises and ambulation assistance using a front-wheeled walker (FWW) with an ankle foot orthosis (AFO). The documentation showed several dates where these interventions were not carried out, potentially affecting the resident's joint and muscle integrity. Similar deficiencies were noted for Residents 40 and 121, who did not receive the required ROM exercises and ambulation support as per their physician orders, further highlighting the facility's failure to maintain and improve residents' mobility and ROM as required.
Staffing Deficiencies Lead to Missed Treatments and Delayed Medications
Penalty
Summary
The facility failed to ensure sufficient staffing of Restorative Nursing Aides (RNAs) to provide necessary treatments to residents with limited range of motion and mobility. Specifically, on multiple occasions, there were not enough RNAs available to cover all nursing stations, leading to missed RNA treatments for several residents. For instance, on certain days, only one RNA was available to cover multiple stations, making it impossible to provide the required treatments to all residents. This staffing issue was compounded by RNAs being pulled from their duties to cover Certified Nursing Assistant (CNA) roles when CNA staff were absent. The deficiency affected several residents, including Resident 62, who had physician orders for active assistive range of motion exercises five times per week. Documentation revealed numerous dates where these exercises were not provided, indicating a failure to meet the resident's care plan. Similarly, Resident 109, who required passive range of motion exercises and the application of various splints, also missed treatments on multiple occasions. The lack of RNA services was documented over several months, highlighting a persistent staffing issue. Additionally, the facility failed to provide sufficient licensed nurses in the subacute unit, resulting in delayed medication administration for several residents. On specific dates, a Licensed Vocational Nurse (LVN) was responsible for 12 residents, and at least three residents did not receive their morning medications on time. This delay in medication administration further underscores the facility's staffing challenges, impacting the timely delivery of care to residents.
Medication Administration Errors Exceed 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below the 5% threshold, resulting in a 6.25% error rate during medication administration. One incident involved a Licensed Vocational Nurse (LVN) administering Mucinex DM to a resident via a gastrostomy tube, despite the physician's order specifying Mucinex (guaifenesin) without DM. The LVN crushed the extended-release tablet, which should not have been crushed, and administered it incorrectly. The resident had a history of malignant neoplasm of the hypopharynx and esophagus, and chronic obstructive pulmonary disease. Another incident involved the administration of Zosyn to a resident via intravenous infusion. The Registered Nurse (RNS) prepared and administered the medication in 100 ml of normal saline, contrary to the physician's order, which specified Zosyn in 50 ml of dextrose. The Director of Nursing confirmed that the medication was not administered according to the five rights of medication administration, which could potentially affect residents with certain conditions sensitive to specific fluid types.
Medication Labeling Discrepancies for IV Antibiotics
Penalty
Summary
The facility failed to ensure that intravenous (IV) antibiotic medications were labeled in accordance with physician orders for two residents. During an observation, a Registered Nurse Supervisor (RNS 4) was administering an IV medication to Resident 22. The label on the medication indicated it was piperacillin sodium and tazobactam sodium (Zosyn) 3.375 grams in 100 milliliters of normal saline. However, the physician's order for Resident 22 specified the medication should be piperacillin sodium-tazobactam sodium in dextrose 3-0.375 grams/50 milliliters, to be infused at 25 cubic centimeters per hour for four hours every eight hours for a urinary tract infection. Similarly, for Resident 44, the IV medication label did not match the physician's order. The label indicated Zosyn 3.375 milligrams in 100 milliliters of normal saline, while the physician's order specified Zosyn intravenous solution 3-0.375 grams/50 milliliters in dextrose, to be administered for pneumonia. These discrepancies in medication labeling had the potential to lead to medication errors, as the labels did not align with the prescribed orders for the residents.
Ice Machine Lacks Air Gap for Backflow Prevention
Penalty
Summary
The facility failed to ensure the ice machine had an air gap for backflow prevention, which is a requirement according to the FDA Food Code 5-202.13. During an observation on March 11, 2025, it was noted that the ice machine pipe leading to the drain had black grime and dirt on it, and there was no air gap between the pipe and the ice machine drain. This was confirmed during a subsequent observation and interview on March 14, 2025, with the Assistant Dietary Supervisor, who acknowledged the presence of black dirt on the pipe and was unaware of the air gap regulation. Further observations and interviews on the same day with the Registered Dietician and the Maintenance Supervisor revealed that both were unaware of the air gap requirement and noted the presence of dirt and black grime on the pipe. The Maintenance Supervisor, who had worked at the facility for several years, admitted the possibility of residents getting sick from contaminated ice. The Administrator was aware of the federal regulation and acknowledged the potential for contaminated water to backflow into the ice machine, posing a risk of waterborne illness to residents.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to provide accurate documentation for five residents with limited range of motion and mobility, leading to deficiencies in care. For Resident 62, the facility did not include a task for the Restorative Nursing Aide (RNA) to perform active assistive range of motion (AAROM) exercises on the right leg, as per the physician's order. This omission was confirmed during an interview with the Director of Medical Records, who acknowledged the lack of documented evidence for AAROM exercises on the right leg over a year. Resident 40's documentation was also incomplete, as it did not include a task for the RNA to perform passive range of motion (PROM) on the left arm during the day shift, despite physician orders. The Director of Staff Development confirmed this was a documentation error, as the task was incorrectly assigned to the night shift, which the RNA would not see. Similarly, Resident 112's documentation failed to include Omni-cycle exercises for both arms, as required by the physician's order, and the facility lacked evidence of these exercises being performed. For Resident 133, there was a clinical record error in the physician's order, which inaccurately required AAROM for the right leg, despite the resident's inability to move the right side of the body. This error persisted for eight months before being corrected. Additionally, Resident 109's treatment notes did not document the application of various splints during physical and occupational therapy sessions, and there was no evidence of speech-language pathology treatment attempts, as the therapist did not document these due to system access issues. These documentation failures resulted in inaccurate care provision for the residents involved.
Infection Control Deficiencies in Linen Handling and Gait Belt Disinfection
Penalty
Summary
The facility failed to maintain proper infection control practices in several areas, leading to potential cross-contamination and risk of infection spread among residents. One of the deficiencies involved the failure to maintain the recommended temperature in one of the linen dryers. During an observation, the dryer was found to be operating at 130 degrees Fahrenheit, below the required 160-170 degrees Fahrenheit necessary to kill germs. The Maintenance Supervisor was unable to explain the discrepancy, which could contribute to the spread of infection throughout the facility. Another deficiency was observed in hand hygiene practices. A Certified Nurse Assistant (CNA) was seen moving between resident rooms without performing hand hygiene, which is crucial to prevent the transmission of germs from one resident to another. The CNA acknowledged the lapse in protocol, and the Infection Prevention Nurse confirmed that such practices could lead to the spread of infections. Additionally, a Laundry Aid was observed handling clean linens without performing hand hygiene after sorting dirty linens, further breaching infection control protocols. The facility also failed to properly disinfect cloth gait belts used by residents. The belts, made of porous cotton, were cleaned with disinfecting wipes intended for hard, non-porous surfaces, rendering the cleaning ineffective. This improper disinfection practice was observed with multiple residents, including those with cancer, coronary artery disease, heart failure, and diabetes mellitus, who required assistance with transfers and walking. The Infection Prevention Nurse confirmed that the use of inappropriate disinfecting methods on porous surfaces could lead to the transmission of infections between residents.
Non-Functional Washer Temperature Gauges in Laundry
Penalty
Summary
The facility failed to ensure that laundry washers were maintained in operational condition, specifically regarding the functionality of the washer temperature gauges. During an observation and interview, it was noted that three out of three washer temperature gauges were not functioning properly. The Maintenance Supervisor (MS) admitted that the gauges do not always work and instead used a thermometer to check the sink water temperature, which he believed shared the same water pipeline as the washers. The MS had reported this issue to the previous Administrator but not to the current one. Additionally, the Laundry Aide (LA) 1 confirmed that the washer temperature gauges had been non-functional for several weeks but had not reported it to anyone. LA 1 also used a thermometer to check the sink water temperature, believing it should be at 160 degrees Fahrenheit to prevent the spread of infection. The Director of Nursing (DON) stated that checking the washer temperatures via the sink is incorrect and emphasized the importance of having functioning washer temperature gauges to prevent infections and potential illnesses among residents. The facility's policy and procedure for laundry and linen, revised in 2014, indicated that linens should be washed in water at least 160 degrees Fahrenheit for a minimum of 25 minutes. The Maintenance Supervisor's job description included the responsibility to identify, report, and schedule repairs for any equipment malfunctions, which was not adequately fulfilled in this instance.
Failure to Notify Physician and Complete Change of Condition
Penalty
Summary
The facility failed to complete a Change of Condition (COC) and notify the physician for two residents, leading to a deficiency in care. Resident 48, who was diagnosed with paranoid schizophrenia and major depressive disorder, expressed a desire to die. Despite this significant change in mental status, the facility did not notify the physician or complete a COC, which would have facilitated closer monitoring and psychological intervention. Licensed Vocational Nurse (LVN) 1 acknowledged the oversight, stating that the physician should have been informed to prevent potential self-harm. Additionally, Resident 362, who has a diagnosis of hypothyroidism, missed scheduled doses of thyroid medication on two occasions. The Registered Nurse Supervisor (RNS) 2 confirmed that the physician was not notified, and a COC was not completed, which could have led to a deterioration in the resident's thyroid condition. The Director of Nursing (DON) emphasized the importance of notifying the physician and completing a COC in such situations to ensure proper monitoring and care. The facility's policies also mandate immediate physician notification and documentation of any significant changes in a resident's condition.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) Level II was completed for a resident with serious mental illness, which is a requirement for appropriate placement and service provision. The resident, who was admitted and readmitted with diagnoses of major depressive disorder and schizoaffective disorder, was taking antipsychotic medication. The Minimum Data Set (MDS) indicated moderate cognitive impairment, and the resident's PASARR Level I screening had identified the need for a Level II evaluation due to the presence of a serious mental illness. Despite the PASARR Level I screening indicating the necessity for a Level II evaluation, no such evaluation was found in the resident's records. Interviews with the MDS coordinator and the Director of Nursing confirmed the oversight, acknowledging that the resident could have missed out on specialized mental health services. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, and if indicated, referred for a Level II evaluation. However, this process was not followed, leading to the deficiency.
Failure to Implement Care Plan for Suicidal Ideation
Penalty
Summary
The facility failed to implement a care plan for a resident, identified as Resident 48, who was admitted with diagnoses including paranoid schizophrenia, major depressive disorder, and cerebral infarction. The resident was moderately cognitively impaired and required substantial assistance with daily activities. During an observation, the resident expressed a desire to die in the presence of an LVN, who stated she would notify her charge nurse immediately. However, it was found that there was no care plan addressing the resident's verbalization of wanting to die. Interviews with facility staff, including an LVN, a Registered Nurse Supervisor, and the Director of Nursing, confirmed that a care plan should have been in place for Resident 48's expression of suicidal ideation. The facility's policy on comprehensive care plans indicated that each resident's care plan should incorporate identified problem areas and risk factors to prevent or reduce declines in functional status. The absence of a care plan for Resident 48's suicidal ideation was a deficiency that could potentially delay care and treatment for the resident.
Failure to Schedule Timely IDT Meeting for Resident
Penalty
Summary
The facility failed to ensure that an Interdisciplinary Team (IDT) meeting was scheduled within 72 hours after the admission of a resident, identified as Resident 218. This resident was admitted with multiple injuries, including fractures from a motor vehicle accident, and was dependent on staff for various activities of daily living. Despite the facility's policy requiring an IDT meeting within 72 hours to discuss the resident's plan of care, no such meeting was scheduled or documented, leaving the resident unaware of his care plan. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse Supervisor (RNS), and the Social Services Director (SSD), confirmed the oversight. The SSD acknowledged the failure to schedule the IDT meeting and noted that attempts to contact the resident's family were made only after the deficiency was identified. The Director of Nursing (DON) also confirmed that the resident was alert and oriented and emphasized the importance of the resident being informed about his care plan to prevent potential refusal of care. The facility's policies and procedures outlined the necessity of involving residents in care planning and ensuring they are informed about their treatment and discharge plans. However, the lack of documentation and scheduling of the IDT meeting for Resident 218 indicates a deviation from these policies, resulting in the resident not being involved in his care planning process.
Failure to Provide Scheduled Showers and Skin Inspections
Penalty
Summary
The facility failed to provide necessary care and services for Resident 154, who was dependent on assistance for activities of daily living (ADLs) such as bathing, dressing, and toileting. Resident 154, who was admitted with multiple diagnoses including Stage 4 pressure injuries and functional quadriplegia, did not receive scheduled showers or bed baths as required. The facility's records indicated that Resident 154 was only showered twice since admission, despite being scheduled for showers twice weekly. This lack of proper hygiene care was confirmed through interviews with staff members, who acknowledged the absence of skin inspection sheets and the failure to provide scheduled showers or bed baths. The deficiency was further highlighted by the absence of skin inspection sheets for certain months, indicating that Resident 154 did not receive the necessary skin inspections during showers or bed baths. Certified Nursing Assistant (CNA) 3, who was responsible for assisting with ADLs and conducting skin inspections, confirmed that Resident 154 did not receive showers on scheduled days and that skin inspections were not performed. The Director of Staff Development and other nursing staff corroborated these findings, emphasizing the importance of regular bathing and skin inspections to prevent further skin breakdown and pressure injuries. The facility's policy and procedure documents, as well as the CNA job description, outlined the requirement for providing assistance with ADLs, including bathing and skin inspections. However, these procedures were not followed, resulting in Resident 154 not receiving the necessary care to maintain good grooming and personal hygiene. The failure to adhere to the established care plan and shower schedule contributed to the resident's ongoing pressure injuries and potential delay in wound healing.
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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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