Westwood Post Acute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 12121 Santa Monica Boulevard, Los Angeles, California 90025
- CMS Provider Number
- 055060
- Inspections on file
- 71
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Westwood Post Acute Care during CMS and state inspections, most recent first.
Staff did not include a known pattern of wound care refusal in a resident’s baseline care plan, despite multiple documented refusals of ordered treatment for a right shin venous stasis ulcer. The resident, with COPD, depression, and dementia but intact decision-making per MDS, told Social Services and nursing staff that he preferred to have his wound treated at a GACH and at times declined facility wound care. TARs showed repeated refusals, and interviews with an LVN, treatment nurse, RN supervisor, and ADON confirmed that the resident was known to refuse care and that care plans are expected to be resident-specific and cover all care needs, yet the baseline care plan did not address the behavior of refusing wound care.
A resident with hemiplegia, hemiparesis, DM2, and HTN, who had moderate cognitive impairment and required staff assistance with ADLs, requested transfer to a facility in another city to be closer to family. Over several months, the resident and responsible party reported not being informed about the transfer process, not receiving a list of potential facilities, and not being able to speak with the ADM, while also receiving conflicting explanations about why the transfer could not occur. The SS director acknowledged the family’s ongoing request and that at least one potential receiving facility would not accept the resident’s insurance, but the facility did not assist with necessary insurance changes or document timely referrals or transfer planning, despite a care plan that called for discussing placement options and reviewing insurance verification as needed, resulting in an unreasonable delay in the resident’s requested transfer.
Surveyors found expired tomatoes and undated wilted celery in the refrigerator, indicating that food items were not removed as required by facility policy. The dietary supervisor confirmed that all food should be labeled and disposed of after the use by date, but this procedure was not followed.
Surveyors identified deficiencies in the dietary department, including unclean kitchen equipment, improper storage of partially cooked food, and failure to label and date potentially hazardous foods. Staff did not consistently follow menus or recipes, and required annual competency evaluations and performance reviews for dietary staff were missing.
A bedbound, visually impaired resident with Alzheimer's disease did not have a call light within reach and was unaware of its purpose, as confirmed by staff interviews and observation. The call light was found out of reach, and staff acknowledged the importance of accessibility and education for newly admitted residents per facility policy.
A resident with a full-code POLST was found unresponsive and pulseless in a wheelchair on the patio. Instead of starting CPR immediately as required by AHA guidelines and facility policy, staff moved the resident to his room before initiating resuscitation. Multiple staff and a physician confirmed that CPR was not started at the scene, resulting in a delay before emergency measures began. Paramedics later pronounced the resident dead after unsuccessful resuscitation.
A resident with multiple medical conditions was discharged to an ALF without proper coordination or communication regarding their gastrostomy tube, medication supply, or home health services. The facility did not regularly re-evaluate the discharge plan, failed to involve the resident's representative in the process, and did not notify the receiving ALF of the resident's g-tube. As a result, the resident arrived at the ALF unprepared, lacking necessary medication and home health arrangements, and the ALF had to arrange for additional medical care post-discharge.
The facility did not develop a care plan for a resident with a gastrostomy tube, omitting necessary interventions and monitoring, and also failed to initiate a discharge care plan for another resident with cognitive and physical impairments. These omissions were confirmed by the DON and were not in accordance with facility policy.
A resident with Parkinson's disease, muscle weakness, and other physical impairments was unable to use the standard call light due to insufficient hand strength, leaving them unable to call staff for assistance. The issue was confirmed by a CNA, who noted the resident's inability to press the call light button and suggested a more accessible option.
A resident with multiple health conditions and severe cognitive impairment experienced a decline in a pressure ulcer after staff failed to timely implement a care plan intervention for a Low Air Loss (LAL) mattress, despite physician orders and facility policy requiring pressure reduction devices for residents at risk of skin breakdown.
A resident with severe cognitive impairment and multiple chronic conditions had incomplete and missing documentation of ADLs over several days. The DON confirmed that the lack of documentation was due to CNAs not having access to iPads, which had been stolen and not replaced, resulting in shared computer use and missed entries.
A medication error occurred when an LVN attempted to administer Empagliflozin (Jardiance) to a resident despite a physician's hold order and left the medication unattended at the bedside for a family member to give. The resident, who had diabetes and other chronic conditions, had the medication on hold per physician and family request, and the error was acknowledged by nursing staff as a failure to follow standard medication administration procedures.
Twelve residents requiring feeding assistance were labeled as 'feeders' by staff, who maintained a list with this term to assign care duties. Staff, including CNAs, LVNs, the DON, and the MDS coordinator, routinely used this terminology in both verbal and written communications, despite facility policy requiring respectful and dignified treatment. The residents affected had significant medical and cognitive needs, and the practice was acknowledged as standard among staff.
The facility did not ensure that advance directives were present and up-to-date in the clinical records for three residents with various medical conditions and cognitive statuses. During record reviews and interviews, an LVN confirmed the absence of these documents, which could cause confusion about residents' healthcare wishes in emergencies, contrary to facility policy.
An independent liaison, not affiliated with the facility or hospice, accessed and retained a resident's medical records without consent or proper authorization. The liaison did not meet with the resident or obtain consent, and used information from the records to arrange a discharge to hospice care. The resident had a terminal prognosis and intact decision-making capacity. Facility policy required limiting access to PHI, but this was not followed, resulting in a HIPAA violation.
A resident with diabetes, hyperlipidemia, stroke history, and hypertension was found to be cognitively intact but unaware of the reason for her insulin therapy. Review of her medical record showed no documentation that DM education was provided, despite facility policy requiring such documentation after new diagnoses. Both the RN Supervisor and DON confirmed the absence of required education documentation.
A resident with multiple medical conditions was found with topical medications and powder at the bedside, despite not being approved for self-administration according to facility assessment and policy. An LVN confirmed that medications should not be left at the bedside for residents not cleared for self-administration, and the DON stated that proper assessment and physician orders are required before allowing self-administration.
A resident did not have access to hot water for personal hygiene, and the cold water faucet in their room splashed water onto the resident and the floor. The TV was loose and tilted, and the window blinds were broken and improperly attached, creating an unsafe and uncomfortable environment. Facility staff confirmed these issues and identified the need for repairs.
A resident with a history of stroke, generalized weakness, diabetes, cognitive impairment, and dependence on staff for daily living did not have a baseline care plan developed as required by facility policy. The absence of this care plan, particularly for gastrostomy tube management, was confirmed by interviews with nursing leadership and was identified during record review.
A resident with cognitive impairment and multiple hospitalizations for g-tube dislodgement did not have an IDT meeting conducted as required by facility policy. Despite repeated changes in condition, there was no documentation that the resident or their representative were involved in care planning or decision-making, as confirmed by interviews with the ADON and DON.
A resident's room was found to have a loose, tilting TV and broken, bent blinds that were not properly attached, creating potential accident hazards. The resident, who was cognitively intact and independent, reported these issues, which were confirmed by observation and staff interviews. Facility policy requires rooms to be safe and well-maintained, but these hazards were not addressed at the time of the survey.
A resident with cognitive impairment and multiple medical conditions did not receive prescribed enteral nutrition when the feeding tube connection device was found on the floor and not attached to the gastrostomy tube, despite the feeding pump running. An LVN confirmed the improper connection, and the DON noted this could result in the resident not receiving necessary nutrition, contrary to facility policy.
A resident's protected health information was accessed and retained by an independent liaison who was not affiliated with the facility or hospice company. The liaison obtained the resident's medical records without consent and used the information to arrange a discharge to home hospice, without confirming the resident's wishes or involving the family in advance. Facility leadership confirmed the liaison was not authorized to access or use the resident's records, resulting in a violation of HIPAA privacy standards.
Two residents were not offered or administered the pneumococcal vaccine at admission as required by facility policy, and there was no documentation of consent or declination forms until a later date. This occurred despite both residents being cognitively intact and the facility's stated process for screening and documenting vaccination status.
Two residents were not properly offered or documented for COVID-19 vaccination as required by facility policy. Both residents, who were cognitively intact and had multiple medical conditions, lacked evidence of a consent or declination form for the vaccine in their records, despite the facility's process requiring this documentation upon admission.
A resident with type 1 diabetes did not receive insulin as ordered when blood sugar was critically high, and staff failed to consistently monitor and document blood sugar levels before administering insulin. Insulin was sometimes given without a current blood sugar reading, and required physician notifications for abnormal results were missed. These actions and omissions resulted in inadequate diabetic management and confusion among staff regarding appropriate interventions.
The facility failed to ensure staff were seated while feeding two residents, compromising their dignity and comfort. Observations showed CNAs standing over residents with severe cognitive impairments, contrary to facility policy. Interviews confirmed staff awareness of the requirement to sit, but one CNA cited a lack of available chairs as a reason for standing.
A resident with atrial fibrillation, muscle weakness, and polyneuropathy experienced delays in having their call light answered, despite the facility's policy requiring prompt responses. The resident reported that staff sometimes turned off call lights without returning to assist. During an observation, the call light remained on for over 10 minutes while staff were present in the hallway and nursing station, and an alarm was sounding. A nurse confirmed the expectation for prompt responses but could not explain the delay.
A resident with hemiplegia and CHF experienced a fall resulting in a forehead bump and headache. The facility failed to develop a comprehensive care plan with goals and interventions following the incident, as required by their Fall Management Program policy. This deficiency was confirmed by the Medical Record Director during a record review and interview.
A resident with a history of hemiplegia and CHF was found unresponsive and pronounced dead by paramedics. The facility failed to follow its policy requiring a physician's declaration of death and proper documentation, resulting in missing progress notes and a death certificate in the resident's medical records.
The facility failed to provide adequate respiratory care for two residents by not ensuring a physician's order for oxygen therapy and not changing nasal cannula tubing and humidifiers as per policy. One resident was using an oxygen concentrator without a physician's order, and both residents had unlabeled and unchanged equipment, contrary to facility policy.
Two residents experienced misappropriation of belongings due to the facility's failure to follow its theft and loss policy. One resident lost clothes after a scabies outbreak, and another lost clothes and neck pillows, with no inventory or labeling in place. Staff interviews confirmed the lack of initiated reports and adherence to procedures.
A resident with a history of falls and assessed as high risk was left unattended in a wheelchair, resulting in an unwitnessed fall and a laceration requiring sutures. Staff interviews revealed that both the charge nurse and a CNA were on break or attending to personal tasks at the time, and the facility's fall management policy requiring frequent observation was not followed.
The facility failed to implement effective infection control measures, leading to potential infection spread among residents. Three residents with severe cognitive impairments were not assessed for skin rashes, placed on contact precautions, or had their physicians notified about ineffective treatments. Observations revealed red, raised, scaly rashes and burrowing, indicating possible scabies. The facility's infection control policy was not followed, contributing to the deficiency.
A resident with a G Tube experienced multiple dislodgements due to the facility's failure to consistently use an abdominal binder, as outlined in the care plan. Additionally, there was a delay in transferring the resident to the hospital after the G Tube malfunctioned, risking malnutrition and dehydration. The facility also lacked adequate training and policies on bowel impaction and abdominal assessments, contributing to the resident's fecal impaction and associated complications.
A resident reported her personal walker missing upon readmission to the facility, but no grievance form was initiated, and there was no documentation of her report. Despite staff being aware of the issue, the facility failed to follow its grievance and theft and loss policies, resulting in a violation of the resident's rights.
A resident with a history of stomach cancer and severe pain was not administered Norco as ordered by the physician, resulting in unmanaged pain. Despite the resident's reports of severe pain and the facility's policy requiring pain management, the medication was not given during night shifts, and no interventions were documented. Interviews with the ADON and DON confirmed the oversight.
A resident with hypertension, diabetes, and dementia, who was on hospice care, passed away without proper documentation in their medical record. The facility did not follow its policy on documenting the death, as confirmed by the DON.
A facility failed to educate a visitor on the use of PPE for a resident under droplet precautions due to COVID-19 exposure. The resident, with a history of hemiplegia, COPD, and diabetes, was in a room with droplet precaution signage, but the visitor was not informed about PPE requirements. Staff interviews confirmed the need for visitor education on PPE, as outlined in the facility's COVID-19 management policy.
A resident at risk for unplanned weight loss experienced significant weight loss due to the facility's failure to implement dietary recommendations. Despite a Registered Dietician's advice to provide ice cream with meals and snacks, these were not followed, resulting in a 3% body weight loss in one week. The Director of Nursing highlighted the importance of adhering to dietary plans to prevent such outcomes.
A resident with prostate cancer did not receive the prescribed medication Darolutamide due to its high cost and lack of insurance coverage. The facility failed to notify the physician or oncologist, resulting in a breakdown of communication and adherence to medication administration policies. Staff interviews revealed assumptions and lack of documentation regarding the missing medication.
A resident with severe cognitive impairment and a history of abdominal issues was not properly monitored or reported to a physician when symptoms of abdominal distention and inconsistent bowel movements were observed. Despite staff noticing these changes, the required notification to the physician was not made, leading to the resident being found unresponsive and later pronounced dead. The facility's policy on Change of Condition Notification was not followed, contributing to the deficiency.
A resident with a history of falls and psychosis experienced multiple falls and injuries due to the facility's failure to provide a full-time 1:1 sitter as outlined in their care plan. Despite being assessed as high risk for falls, the resident fell on several occasions, resulting in injuries such as a dislocated finger, a fractured ulna, and a hematoma. The facility did not consistently implement care plan interventions, and staff acknowledged the ineffectiveness of these measures in preventing the falls.
The facility failed to maintain a safe and functional area in the staff's breakroom, where multiple dead roaches were found under the sink. The Maintenance Supervisor acknowledged the issue, and the Administrator confirmed that the Maintenance and Housekeeping staff would clean the breakroom and remove the dead roaches. The facility's policies indicated that the facility should be free of pests and maintained in a clean and sanitary condition.
The facility failed to promote dignity and respect for two residents by not conducting a personal property inventory upon admission for one resident and allowing staff to speak in a language not understood by another resident in their presence. This led to missing belongings and feelings of exclusion and anger.
The facility failed to ensure comfortable sound levels at night, affecting three residents' ability to sleep undisturbed. Residents reported high noise levels, particularly from staff activities, which were confirmed by staff interviews. The facility's policies emphasize maintaining comfortable noise levels, but these were not followed.
The facility failed to conduct timely PASRR for two residents, leading to potential inappropriate care. One resident's PASRR was incomplete, and another's was delayed by several months. The facility's policies were not followed, compromising the care provided.
The facility failed to store and label food in accordance with professional standards and facility policy, placing residents at risk for foodborne illnesses. Observations revealed expired and unlabeled food items in the kitchen and the refrigerator used for residents' outside food. The Dietary Supervisor and Maintenance Assistant acknowledged the issues and the potential health risks.
The facility failed to obtain a physician's order for a resident to go out on pass, despite the resident's threats and previous doctor's order for a one-day pass. This non-compliance with facility policy potentially impacted the resident's psychosocial well-being and self-esteem.
The facility failed to ensure a comprehensive PASRR assessment for a resident with major depressive disorder, anxiety disorder, and PTSD. The PASRR level 1 screening had a blank question regarding suspected mental illness, which could lead to inadequate care. Only one RN had access to the PASRR system, and the facility's policy mandates that incomplete PASRRs must be completed the same day.
Failure to Include Wound Care Refusal in Baseline Care Plan
Penalty
Summary
Facility staff failed to develop and implement a baseline, individualized care plan within 48 hours of admission that addressed a resident’s known behavior of refusing ordered wound care. The resident was admitted with COPD, depression, and unspecified dementia, and an MDS assessment indicated intact cognitive skills for daily decision-making. Social Services documentation showed that the resident refused wound care on at least one occasion, stating he would skip treatment that day and have it done the next day, and the physician was notified of these episodes of refusal. The resident’s orders included daily treatment of a right shin venous stasis ulcer with normal saline cleansing, xeroform, and dry dressings on the day shift. Review of the resident’s baseline care plan revealed that it did not address the resident’s repeated refusals of wound care, despite the Treatment Administration Records documenting refusals on multiple dates in February and March. During interviews, the resident stated he preferred to have his wound changed and treated at a general acute care hospital where he frequently had appointments. Facility staff, including an LVN, the treatment nurse, the RN supervisor, and the ADON, acknowledged that the resident was known to refuse care and that care plans are essential, resident-specific, and must cover all areas of care needs. The treatment nurse confirmed that wound treatment nurses are responsible for initiating and updating wound care and that the resident’s baseline care plan did not include care planning for refusal of wound care, even though refusals continued to occur.
Failure to Assist Resident With Requested Transfer and Insurance Coordination
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to self-determination and choice regarding transfer to another skilled nursing facility closer to family. A resident with diagnoses including hemiplegia, hemiparesis, type 2 diabetes mellitus, and essential primary hypertension, and with documented moderate cognitive impairment and dependence on staff for several ADLs, expressed a desire to transfer to a facility in Bakersfield to be closer to his sons. The resident reported wanting this for some time and stated he was not informed about the transfer process and was unaware of what was happening, indicating reliance on his responsible party to handle the transfer. The responsible party stated that it had been almost three months since the resident’s desire and request to transfer were communicated to the facility, but they were not provided with a list of available facilities in Bakersfield and did not receive consistent information about why the transfer could not occur. The responsible party further reported not being able to speak with the administrator despite requests and not receiving assistance from the facility in changing the resident’s insurance so that Bakersfield facilities could accept the resident. The social services director confirmed that the family had requested a transfer to Bakersfield for at least one to three months and acknowledged that a contacted Bakersfield facility did not accept the resident’s insurance, stating that changing insurance was the responsibility of the resident or responsible party. Progress notes showed that social services spoke with an admissions director at a Bakersfield facility and learned they did not take the resident’s insurance, but records did not show referrals or transfer plans prior to the complaint investigation date. The resident’s discharge care plan, which included interventions to discuss placement options as requested and review insurance verification and authorization as needed, did not reflect that these interventions were implemented before the complaint, resulting in an unreasonable delay and impediment to the resident’s requested transfer.
Failure to Remove Expired Food from Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to remove expired food items from the refrigerator in accordance with their policy. Specifically, a bin of tomatoes with a use by date that had passed and a bin of wilted celery with no date were found during an inspection. The facility's produce storage guidelines require that fresh vegetables be checked for ripeness, labeled, dated, and rotated so that the oldest produce is used first, and that expired items be disposed of. During an interview, the dietary supervisor confirmed that all deliveries are labeled upon receipt and should be discarded after the use by date, but this was not followed in practice.
Deficiencies in Food Safety Practices and Staff Competency in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food and nutrition service. The kitchen stove top was found with dried food and debris, and the refrigerator contained unlabeled and undated slices of cheese, a large container of egg salad, and a large container of tuna. During the inspection, a dietary cook was found storing partially cooked chicken and zucchini in the oven at 250 degrees, claiming it was not being cooked but stored. The cook did not follow the prescribed menu or recipe for meal preparation. The cook became visibly angry during the inspection, slamming hot pans and oven doors, which led the surveyor to exit the kitchen for safety concerns. The dietary supervisor confirmed that recipes and menus are to be followed unless changes are approved, and the dietician emphasized the importance of labeling and dating potentially hazardous foods. Further review of employee records revealed that annual competencies and performance evaluations were missing for multiple dietary staff members, including cooks and aides. The Director of Staff Development acknowledged that these evaluations are required to ensure staff competency and safe food preparation. Facility policies reviewed indicated that standardized recipes and menu adherence are mandatory, and that staff competency checks should be performed upon hire, annually, and as needed. The lack of adherence to these policies and procedures contributed to the observed deficiencies in food safety and staff competency.
Failure to Ensure Call Light Accessibility and Resident Education
Penalty
Summary
A deficiency occurred when a bedbound resident with blindness, muscle weakness, dysphagia, and Alzheimer's disease did not have access to a call light while in bed. During observation, the call light was not visible or within reach of the resident, and the resident stated they were unaware of what a call light was, indicating they had not been educated on its use. The call light was later found on a nightstand under a pillow, out of the resident's reach by more than an arm's length. Staff interviews confirmed that the call light should have been accessible and that education on its use is required upon admission. The CNA admitted to forgetting to check the call light's placement, and the LVN and DSD both acknowledged the importance of call light accessibility and resident education, especially for newly admitted, visually impaired, and primarily Spanish-speaking residents. Facility policy requires that residents be instructed on the use of the call system upon admission.
Failure to Immediately Initiate CPR for Unresponsive Resident
Penalty
Summary
Facility staff failed to immediately initiate cardiopulmonary resuscitation (CPR) in accordance with American Heart Association (AHA) guidelines for a resident who was found unresponsive in the patio. The resident had a valid Physician Orders for Life-Sustaining Treatment (POLST) indicating a desire for full resuscitation and no advance directive limiting care. Upon discovery, the resident was unresponsive, with no vital signs appreciated, and was seated in a wheelchair. Instead of starting CPR at the location where the resident was found, staff moved the resident from the patio to his room before initiating CPR. Multiple staff members, including a Registered Nurse Supervisor (RNS), were involved in transferring the resident back to bed, which required six to seven people. Interviews with staff and another resident confirmed that CPR was not started on the patio, despite the resident being unresponsive and pulseless. The facility's policy and AHA guidelines both require immediate initiation of CPR when a person is found unresponsive and not breathing normally, but this was not followed in this instance. The delay in starting CPR was further corroborated by interviews with staff, a resident witness, and the facility's medical doctor, who all stated that CPR should have been started immediately at the site where the resident was found. The medical doctor also confirmed that the patio floor was an appropriate surface for CPR. Paramedics arrived after the resident had been moved to his room and found the resident pulseless and unresponsive, with CPR in progress. The resident was pronounced dead by paramedics after resuscitation efforts were unsuccessful.
Failure to Coordinate Discharge Planning and Communication for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure proper discharge planning and coordination for a resident with complex medical needs. The resident, who had a history of hemiplegia, hemiparesis, cerebral infarction, primary thrombophilia, depression, aphasia, seborrheic dermatitis, dysphagia, gastrostomy, hyperlipidemia, glaucoma, and coronary artery disease, was discharged to an assisted living facility (ALF) without adequate communication or preparation. The discharge process did not include regular re-evaluation of the discharge plan, nor was there effective coordination with the resident's representative. The resident's legal guardian participated in initial goal setting, but the overall discharge goal remained unclear, and no referrals were made to local contact agencies as required. During the discharge process, the facility did not ensure that the ALF was notified of the resident's gastrostomy tube, nor did it provide the resident with a supply of hydroxyzine, a medication prescribed for itching. The ALF and care coordinator reported a lack of communication from the facility's Director of Social Services (DSS), resulting in the ALF being unaware of the resident's g-tube and the need for home health services. The resident arrived at the ALF with the g-tube still in place, no home health services arranged, and without all necessary medications. The ALF had to arrange for the removal of the g-tube at a hospital and struggled to set up home health due to insurance issues. Interviews and record reviews revealed that the DSS did not follow up with the resident, family, or ALF after discharge, and did not provide necessary documentation or coordination for the resident's ongoing care needs. The facility's policies required discharge planning to begin at admission, regular updates to the care plan, and communication with all parties involved, but these steps were not consistently followed. The lack of follow-up and incomplete discharge preparation led to significant gaps in the resident's transition to the ALF.
Failure to Develop Comprehensive Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to develop and implement complete care plans for two residents with specific needs. For one male resident with multiple diagnoses including hemiplegia, dysphagia, and a gastrostomy, the care plan did not address the presence or management of the gastrostomy tube, despite documentation in the Minimum Data Set and physician orders indicating its use for water administration. The care plan only referenced dietary restrictions and dysphagia, omitting any interventions or monitoring related to the gastrostomy tube. The Director of Nursing confirmed that a care plan for the gastrostomy tube was missing, even though it was required. For a female resident with diagnoses including monoplegia, dysphagia, and cognitive impairment, the facility did not initiate a discharge care plan upon admission, as required by facility policy. The Director of Nursing acknowledged that discharge planning should begin at admission and be updated as needed, but there was no evidence of a discharge care plan being developed for this resident. The facility's policy mandates that a comprehensive care plan, including discharge planning, be developed within seven days of the comprehensive assessment, but this was not followed.
Failure to Provide Accessible Call Light for Resident with Physical Limitations
Penalty
Summary
The facility failed to ensure that a resident with significant physical limitations had access to a call light that could be used independently. The resident, who had diagnoses including Parkinson's disease, abnormal posture, muscle wasting, generalized osteoarthritis, and muscle weakness, was cognitively intact but required maximal to total assistance for most activities of daily living. During observation and interview, the resident was unable to locate or use the call light due to insufficient hand strength to press the button, and expressed difficulty in calling for help. A CNA confirmed that the resident was unable to press the call light button and suggested an alternative device for easier use. This deficiency resulted from the facility's inaction in providing a call light system that accommodated the resident's physical limitations, thereby preventing the resident from being able to summon staff assistance when needed.
Failure to Timely Implement Pressure Ulcer Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident at risk for pressure ulcers. The resident, who had multiple diagnoses including diabetes mellitus, abnormal posture, muscle weakness, osteoarthritis, heart failure, hypertension, and dementia, was dependent on staff for most activities of daily living and had severe cognitive impairment. The care plan, dated 2/6/25, specified the use of a Low Air Loss (LAL) mattress to prevent further decline in the resident's pressure ulcer condition. However, despite physician orders for the LAL mattress on multiple dates, the mattress was not installed until several days after a noted decline in the resident's pressure ulcer status. The delay in providing the LAL mattress was attributed to concerns from the resident's family about the risk of falls due to the increased bed height. The Director of Nursing confirmed that the mattress was not put in place until after the resident's condition had worsened. Facility policy required the provision of appropriate mattresses to residents at risk for skin breakdown, but this was not followed in a timely manner for this resident, resulting in a decline in the pressure ulcer.
Incomplete ADL Documentation Due to Lack of CNA Access to Electronic Devices
Penalty
Summary
The facility failed to ensure that medical record documentation of activities of daily living (ADLs) was accurate and complete for one of five sampled residents. The resident in question had multiple diagnoses, including diabetes mellitus, abnormal posture, muscle weakness, generalized osteoarthritis, heart failure, hypertension, and dementia, and was assessed as having severe cognitive impairment. According to the Minimum Data Set (MDS), the resident required significant assistance with most ADLs and had a history of rejecting care on several occasions during the assessment period. A review of the resident's ADL records over a ten-day period revealed multiple instances of missing documentation for essential care tasks such as eating, bed mobility, personal hygiene, toilet hygiene, and oral hygiene across various shifts. During an interview and record review, the Director of Nursing (DON) confirmed the missing documentation and attributed the issue to the theft of iPads used by CNAs for documentation, which had not been replaced. As a result, CNAs had to share computers with nurses, leading to delays and omissions in documentation due to limited access.
Medication Error Due to Failure to Follow Hold Order and Unattended Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow a physician's order to hold the medication Empagliflozin (Jardiance) for a resident with diabetes, hypertension, and atherosclerotic heart disease. The medication was on hold per physician order and family request, as documented in the resident's medical record and medication administration record. Despite the hold order, the LVN attempted to administer the medication during a morning shift and left the medication unattended at the resident's bedside at the request of a family member, intending for the family to administer it after oral care. The LVN acknowledged during an interview that leaving the medication with the family and attempting to administer a medication that was on hold was not standard nursing practice. The registered nurse supervisor confirmed that the medication was on hold and later discontinued, and that the error was discussed with the LVN and the family. The assistant director of nursing also stated that medication administration should be witnessed by licensed staff and that all medication orders, including holds and discontinuations, are clearly visible in the medication administration record. Facility policy and procedure require that medications be administered only as ordered by a physician or licensed independent practitioner, and define a medication error as administering a medication that is not currently prescribed. The LVN's actions in attempting to administer and leaving a held medication unattended constituted a failure to comply with these requirements, resulting in a medication error for the resident.
Residents Labeled as 'Feeders' in Staff Assignments
Penalty
Summary
The facility failed to treat twelve residents who required feeding assistance with respect and dignity by referring to them as "feeders" and maintaining a list labeled as such for staff assignment purposes. Staff, including CNAs, LVNs, the DON, and the MDS coordinator, consistently used the term "feeders" to identify and assign residents needing feeding assistance. This terminology was used in staff communications, written lists, and verbal exchanges, and was acknowledged by multiple staff members during interviews. The list of "feeders" was used to distribute workload among staff, and the term was used both in conversation and in written documentation. The residents involved had significant medical needs, including diagnoses such as diabetes Type 2, muscle weakness, Parkinson's disease, quadriplegia, schizophrenia, hypertension, and anxiety disorder. Most of these residents had severely impaired cognition and required substantial or maximal assistance with all activities of daily living, including eating. Some residents had intact cognition but still required extensive assistance. The use of the term "feeders" was applied regardless of cognitive status, and staff described entire rooms as being "feeders" and discussed their care in these terms. Facility policy required that residents be treated with dignity and respect, including being addressed by their name of choice and prohibiting demeaning practices. However, staff interviews and record reviews confirmed that the practice of labeling and referring to residents as "feeders" was routine and accepted among staff, despite the policy. The report notes that this practice caused or had the potential to cause depression among the affected residents.
Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to maintain accurate and current copies of advance directives in the clinical records for three out of four sampled residents. During record reviews and interviews, it was found that the medical charts for these residents did not contain their advance directives, despite facility policy requiring such documentation. Licensed vocational nursing staff confirmed the absence of these documents in the residents' charts, acknowledging that this could lead to confusion regarding the residents' wishes in the event of a medical emergency. The residents involved had varying medical conditions, including muscle weakness, rheumatoid arthritis, hypertension, atrial fibrillation, and diabetes, with cognitive statuses ranging from intact to moderately impaired. The Minimum Data Set assessments indicated differing levels of assistance required for activities of daily living. The facility's policy states that residents have the right to formulate advance directives and that these should be included in their records, but this was not followed for the residents in question.
Unauthorized Access and Disclosure of Resident Medical Records
Penalty
Summary
A deficiency occurred when an independent liaison, who was not an employee of the facility or the hospice company, obtained and retained medical records for a resident without proper authorization or consent. The liaison stated she did not meet with the resident or the resident's sister prior to arranging the discharge and did not receive the resident's consent to access or review the medical records. The liaison acquired the records from the hospice company and used information from them to facilitate the resident's discharge, despite not having a medical background or a direct relationship with the facility or hospice. The resident involved had a history of paraplegia, essential hypertension, and recurrent urinary tract infections with sepsis, and was readmitted to the facility with a terminal prognosis. The resident's medical records indicated intact cognition and the capacity to make medical decisions. The discharge summary and care plan noted the resident's terminal condition and the plan for a safe transition home, but there was no documentation that the physician spoke to the resident's family about the terminal prognosis. The discharge planning review form was also found to be incomplete. Facility policy required that access to protected health information (PHI) be limited to the minimum necessary and that the entire medical record should not be disclosed unless specifically justified, particularly for non-treatment purposes. The liaison's access and retention of the resident's medical records, without proper consent or justification, constituted a violation of the Health Insurance Portability and Accountability Act (HIPAA) and the facility's own policies regarding the disclosure of PHI.
Failure to Document and Provide Diabetes Education to Resident
Penalty
Summary
Facility staff failed to accurately and completely document diabetes mellitus (DM) education in the medical record for one resident. The resident, who had a history of DM, hyperlipidemia, cerebral vascular accident without residuals, and hypertension, was found to be cognitively intact and required staff assistance with activities of daily living. During an interview, the resident stated she did not know why she was taking insulin, indicating a lack of understanding about her diagnosis and treatment. A review of the resident's chart with the Registered Nurse Supervisor revealed no documented evidence that education regarding the DM diagnosis was provided to the resident or her representative. The facility's process requires that new diagnoses be discussed in an interdisciplinary team meeting with the resident or representative, with documentation in the progress notes. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that documentation of education was missing, and facility policy requires that each discipline document relevant information in the resident's progress notes.
Failure to Prevent Unauthorized Self-Administration of Medication
Penalty
Summary
Facility staff failed to ensure that a resident was properly assessed and approved for self-administration of medications. The resident, who had diagnoses of hypertension, generalized weakness, and diabetes mellitus, was admitted to the facility and had a self-administration assessment indicating a need for assistance with ointments and topical medications. The assessment specifically stated that the resident was not approved for self-administration or for keeping medications at the bedside. Despite this, during an observation, the resident was found with two creams and a powder medication at the bedside, which the resident identified as prednisolone cream, Vitamin A&D ointment, and athlete's foot powder. A Licensed Vocational Nurse confirmed that these medications should not have been left at the bedside, as the resident was not approved for self-administration and all medications should be administered by licensed staff and securely stored. The Director of Nursing stated that the facility's process requires an assessment and a physician's order for self-administration, and that medications should not be left with residents who are not approved, to prevent potential medication errors. The facility's policy also requires IDT and physician determination before allowing self-administration, which was not followed in this case.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for one resident, as evidenced by the lack of access to hot water for grooming and personal hygiene, and a malfunctioning cold water faucet that splashed water onto the resident and the floor. The resident reported that the hot water in the room did not function properly, taking over ten minutes to become warm and then only dribbling out, while the cold water came out at an odd angle and caused splashing. Additionally, the television in the room was loose, tilted to the side, and appeared unstable, and the window blinds were broken, bent, and not properly attached, creating the appearance that they might fall at any time. Observations confirmed the resident's room was clean and free of unusual odors, but the TV was loosely affixed and tilted, and the blinds were in disrepair with broken slats and a bent top. The bathroom faucet did not provide hot water, and the cold water splashed outside the sink. The facility's maintenance supervisor acknowledged these issues, attributing the hot water problem to a possible pipe clog and noting the need for repairs to the faucet, TV bracket, and blinds. Facility policies require the maintenance department to keep the building and equipment safe and operable at all times and to provide residents with a safe, clean, comfortable, and homelike environment.
Failure to Develop Baseline Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop a baseline care plan in accordance with its own policy and procedures for one resident. Record review showed that the resident was admitted and later readmitted with diagnoses including stroke, generalized weakness, and diabetes mellitus. The resident's Minimum Data Set indicated cognitive impairment and dependence on staff for activities of daily living. Despite these needs, there was no baseline care plan developed to address the resident's specific conditions, including the management of a gastrostomy tube (g-tube). Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the absence of a care plan could result in staff not having unified or appropriate interventions for the resident, particularly regarding the risk of g-tube dislodgement. The facility's policy required a comprehensive, person-centered care plan to be developed for each resident to meet their health, safety, psychosocial, behavioral, and environmental needs, but this was not done for the resident in question.
Failure to Conduct Interdisciplinary Team Meeting After Change in Condition
Penalty
Summary
The facility failed to conduct an interdisciplinary team (IDT) meeting for one of three sampled residents, as required by facility policy. Specifically, a resident with a history of cerebral vascular accident, generalized weakness, and diabetes mellitus was admitted and later readmitted to the facility. The resident was noted to have cognitive impairment and was dependent on staff for activities of daily living. From January 2025 onward, the resident experienced multiple hospitalizations due to gastrostomy tube (g-tube) dislodgements. However, there was no documented evidence that an IDT meeting was conducted to address these incidents, despite the facility's policy requiring such meetings upon admission, quarterly, annually, and as needed, particularly at changes of condition. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that IDT meetings should have been held to involve the resident's representative and develop a comprehensive care plan, especially after repeated g-tube dislodgements and hospitalizations. The facility's policy on comprehensive person-centered care planning also specifies that the IDT team must include the resident and their representative. The lack of documented IDT meetings meant that the resident and their representative were not involved in care planning or decision-making regarding the resident's care needs during these significant events.
Failure to Maintain Resident Room Free from Accident Hazards
Penalty
Summary
A deficiency was identified when a resident's room was found to have accident hazards and did not provide a safe, comfortable, and homelike environment. The resident, who was cognitively intact and primarily independent with diagnoses including hypertension and muscle weakness, reported that the television in the room was loose, tilting to the right, and appeared as though it might fall. Additionally, the blinds in the room were broken, bent, and not properly attached, creating the appearance that they could fall at any time. These issues were confirmed during an observation of the room, where the TV was seen to be loosely affixed and the blinds were in disrepair. Interviews with facility staff, including the Maintenance Supervisor, confirmed that the TV had a loose screw and the blinds were damaged, both of which had not yet been addressed at the time of the initial observation. The facility's policies and procedures require that the maintenance department keep the building and equipment safe and operable at all times, and that resident rooms provide a safe, clean, comfortable, and homelike environment. The failure to maintain the resident's room in good repair and free from hazards constituted a deficiency.
Failure to Properly Administer and Connect Enteral Feeding
Penalty
Summary
A deficiency was identified when a resident with a history of cerebral vascular accident, generalized weakness, and diabetes mellitus, who was dependent on staff for activities of daily living and had cognitive impairment, did not receive appropriate care related to their enteral feeding. The resident had a physician's order for Glucerna 1.5 to be administered via gastrostomy tube twice daily at a specified rate. During observation, the feeding tube connection device was found on the floor, disconnected from the resident's gastrostomy tube, while the feeding pump continued to run. Upon further investigation, a Licensed Vocational Nurse confirmed that the feeding tube was not properly connected, which could result in the resident not receiving their prescribed nutrition. The Director of Nursing also acknowledged that the tube feeding set should be a closed unit to prevent infection and that failure to connect the feeding could lead to nutritional deficits. Facility policy required enteral feedings to be administered per physician order and connected to the resident, which was not followed in this instance.
Unauthorized Access and Disclosure of Resident Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards for one resident. An independent liaison, who was not an employee of the facility, hospice company, or corporation, obtained and retained the resident's medical records without the resident's consent. The liaison accessed these records through the hospice company and used the information to arrange for the resident's discharge to home hospice services, despite not having a medical background or prior contact with the resident or their family. The resident in question had a diagnosis of complete paraplegia and essential hypertension, with medical records indicating intact cognition and the capacity to make medical decisions. The resident required significant assistance with activities of daily living. The liaison did not confirm the resident's wishes or obtain consent before accessing and using the resident's protected health information (PHI) for discharge planning. The family was informed by the liaison, who identified herself as a case manager for the corporate office, that the resident needed to be discharged the next day, without prior notice or direct communication from facility staff. Facility leadership, including the Vice President of Operations, confirmed that the liaison was not affiliated with the facility or corporation and had no authorization to access or use the resident's medical records. The facility's failure to control access to PHI resulted in a violation of HIPAA privacy standards, as the liaison was able to obtain, review, and act upon the resident's medical information without proper authorization or consent.
Failure to Offer and Document Pneumococcal Vaccination per Policy
Penalty
Summary
The facility failed to ensure that pneumococcal (PNA) vaccines were offered and/or administered to two of five sampled residents in accordance with facility policy. For both residents, who were cognitively intact and required varying levels of assistance with activities of daily living, there was no documented evidence that a consent or declination form for the PNA vaccine was obtained at the time of admission. Instead, the consents were obtained at a later date, well after their respective admissions. The facility's process, as described by the Infection Prevention (IP) Nurse, involves screening residents upon admission for vaccination status using resident or representative interviews and checking immunization registries, followed by obtaining consent or declination forms based on current vaccination status. Record reviews confirmed that for both residents, the required documentation regarding the offer or administration of the PNA vaccine was missing at admission, contrary to the facility's policy and CDC recommendations. The facility policy, reviewed previously, specified that pneumococcal immunization should be offered according to CDC guidelines, but this was not followed for the two residents identified in the report.
Failure to Document and Offer COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to ensure that COVID-19 vaccination was offered and/or administered to two of five sampled residents in accordance with its policy and procedures. For one resident, the admission record showed they were admitted and readmitted with diagnoses including spinal stenosis, muscle spasm, and GERD. The Minimum Data Set (MDS) indicated the resident was cognitively intact and required assistance with activities of daily living. Upon review of the electronic chart and interview with the Infection Prevention (IP) Nurse, it was found that there was no documented evidence of a consent or declination form for the COVID-19 vaccine for this resident at the time of admission, as required by facility policy. Similarly, another resident was admitted with diagnoses of anemia, generalized weakness, and diabetes mellitus, and was also found to be cognitively intact and moderately dependent on staff for activities of daily living. Record review and interview with the IP Nurse revealed that there was no documented evidence of a consent or declination form for the COVID-19 vaccine for this resident either. The facility's policy, reviewed on 12/18/2020, required that residents be screened for vaccination status and that appropriate documentation be obtained, but this was not followed for the two residents identified.
Failure to Administer Insulin and Monitor Blood Sugar per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with type 1 diabetes mellitus did not receive appropriate insulin administration and blood sugar (BS) monitoring according to physician orders and facility policy. On one occasion, the resident's BS was found to be 541 mg/dL, but the prescribed dose of Humalog KwikPen insulin was not administered, and the physician was not notified as required. Additionally, there were multiple instances where the licensed vocational nurse (LVN) failed to check the resident's BS prior to administering insulin, and in one case, administered insulin based on a BS reading taken several hours earlier without rechecking the current level. The facility's policy required BS checks and physician notification for readings above 350 mg/dL, but these steps were not consistently followed. The resident's medical records indicated a history of type 1 diabetes and essential hypertension, with orders for both scheduled and sliding scale insulin. Documentation showed that the resident experienced a severe hypoglycemic event, with a BS of 25 mg/dL, resulting in unresponsiveness and transfer to the hospital. Despite this event, subsequent insulin administration and BS monitoring remained inconsistent. The LVN involved stated that fear of another hypoglycemic episode influenced the decision not to administer insulin when the BS was high, but this was not communicated to the physician in a timely manner. There were also discrepancies in the documentation of BS checks and insulin administration, with some doses given without recent BS readings and some high BS readings not followed by the required interventions. Interviews with staff and review of facility policies confirmed that the required protocols for diabetic care, including timely BS monitoring, insulin administration, and physician notification, were not adhered to. The director of nursing acknowledged that the nurse should have rechecked the BS before administering insulin and should have notified the physician of significant changes. The facility's policies emphasized the importance of monitoring and documentation, but these were not consistently implemented, leading to confusion among staff and inadequate care for the resident.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to provide care that promoted or enhanced the dignity and respect of residents by not ensuring staff were seated while feeding residents. This deficiency was observed in two residents who required assistance with feeding due to severe cognitive impairments and other medical conditions such as dysphagia and dementia. During observations, Certified Nursing Assistants (CNAs) were seen standing over the residents while feeding them, causing the residents to raise their necks and look up at the staff, which is contrary to the facility's policy that staff should be seated to ensure comfort and dignity for the residents. Interviews with the CNAs and a Licensed Vocational Nurse (LVN) confirmed that the staff were aware of the requirement to sit while feeding residents to maintain their dignity and comfort. However, one CNA did not sit due to the unavailability of a chair, and another CNA initially stood before sitting down after being reminded. The facility's policies, including the Restorative Dining Program and Feeding the Resident, clearly state that staff should sit while assisting or feeding residents, and residents should be properly positioned to facilitate eating.
Failure to Promptly Answer Resident's Call Light
Penalty
Summary
The facility failed to ensure that a resident's call light was answered promptly, which is a device used to notify the nurse that the resident needs assistance. This deficiency was observed for one of the sampled residents, who was admitted with diagnoses including atrial fibrillation, muscle weakness, and polyneuropathy. The resident's cognitive skills for daily decisions were intact, and they required moderate assistance from staff for activities of daily living. During an observation and interview, the resident expressed that staff took a while to answer call lights and sometimes turned them off without returning to assist. On the day of the observation, the resident pressed the call light for help, and it remained on for more than 10 minutes while staff were observed walking in the hallway and present in the nursing station. An alarm sound was heard in the nursing station, indicating that the call light was active. A Licensed Vocational Nurse confirmed that call lights should be answered right away and that any staff could respond to them. However, the nurse was unable to explain why the call light had not been answered promptly. The facility's policy and procedure indicated that call alerts should be answered promptly and courteously, which was not adhered to in this instance.
Failure to Implement Comprehensive Care Plan After Resident Fall
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident following a fall incident with injury. The resident, who had been admitted with conditions including hemiplegia, hemiparesis, and congestive heart failure, experienced a fall on 12/5/2024, resulting in a bump on the forehead and a headache. Despite the incident, there was no care plan developed with goals and interventions to address the fall, as confirmed by a review of the resident's electronic and paper health records. The facility's policy on Fall Management Program, which requires interventions to be documented in the resident's plan of care, was not followed. This deficiency was identified during a record review and interview with the Medical Record Director, who confirmed the absence of a care plan for the resident after the fall incident. The lack of a comprehensive care plan following the fall had the potential to negatively impact the resident's health and safety, as well as the quality of care and services received.
Failure to Document Resident's Death According to Policy
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not implementing the facility's policy and procedure titled 'Death of a Resident' when the resident passed away. The resident, who had a history of hemiplegia, hemiparesis, and congestive heart failure, was found unresponsive by a Certified Nursing Assistant. Paramedics pronounced the resident dead, but there was no physician's progress note or record of death filed in the resident's medical records. The facility's policy required that only a licensed physician could declare a resident dead and that all documentation related to the resident's death should be maintained in the medical record. However, the Medical Record Director confirmed that there were no physician's progress notes or death certificate on file for the resident. This oversight resulted in an incomplete assessment and documentation as required by the facility's policy and procedure upon the resident's death.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents by not ensuring a physician's order was in place for oxygen therapy for one resident and not changing the nasal cannula tubing and humidifier as per facility policy for both residents. Resident 4, who was admitted with diagnoses including atrial fibrillation and muscle weakness, was observed using an oxygen concentrator without a physician's order for supplemental oxygen therapy. Additionally, the nasal cannula tubing and humidifier for Resident 4 were not labeled with a date and the humidifier was empty, indicating a failure to follow the facility's policy of changing and labeling these items weekly. Resident 2, admitted with conditions such as type II diabetes mellitus and heart failure, also experienced deficiencies in respiratory care. The nasal cannula tubing and humidifier for Resident 2 were not labeled with a date and had not been changed since admission, contrary to the facility's policy. The humidifier was observed to be more than halfway empty, and no bubbling was noted, suggesting it was not functioning properly. Licensed Vocational Nurses confirmed these observations and acknowledged the lack of adherence to the facility's policy, which requires weekly changes and labeling of the equipment.
Failure to Protect Residents' Belongings
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their personal belongings. Resident 1, who was admitted with a left femur fracture, bipolar disorder, and depression, reported missing clothes after a scabies outbreak led to her clothes being laundered and stored in the basement. Despite a list being made of her clothes, the items were not returned, and she was given clothes from the donation stock instead. Interviews with staff confirmed that a theft and loss report was not initiated, contrary to the facility's policy. Resident 2, admitted with hemiplegia and hemiparesis following a cerebral infarction, reported missing clothes and neck pillows that were sent to the laundry. The facility failed to maintain an inventory of Resident 2's belongings upon admission, and her clothes were not labeled, making it difficult to identify them. The Assistant Director of Nursing confirmed the absence of an inventory list and acknowledged the need for labeling residents' clothes. The facility's policy on theft and loss requires the initiation of a report and investigation when personal property is reported missing. However, this procedure was not followed for either resident, resulting in the unresolved loss of their belongings. The policy also mandates the documentation of residents' belongings upon admission and the labeling of clothes, which was not adhered to in these cases.
Failure to Supervise High-Risk Resident Leads to Fall
Penalty
Summary
The facility failed to adequately supervise and monitor a resident, identified as Resident 1, who was at high risk for falls. Resident 1 had a history of recurrent falls and was assessed as a high risk for falls, with a fall risk evaluation score of 12, indicating a high risk for potential falls. The resident's care plan included interventions to anticipate and meet the resident's needs and to provide a safe environment. Despite these measures, on the evening of November 8, 2024, Resident 1 suffered an unwitnessed fall from a wheelchair, resulting in a laceration on the left eyebrow that required three sutures. The incident occurred when Resident 1 was left unattended in a wheelchair across from their room. Interviews with staff revealed that both the charge nurse and a certified nursing assistant were on break or attending to personal tasks at the time of the fall. The resident was found on the floor in a prone position by the doorway, with a skin tear and minimal bleeding. The facility's policy on fall management, which requires more frequent observation for residents with multiple falls, was not adhered to, contributing to the incident. The report highlights that the facility's failure to provide adequate supervision and a safe environment for Resident 1, who was known to be at high risk for falls, directly led to the resident's fall and subsequent injury. Interviews with staff and the review of the facility's policies indicate a lack of adherence to established protocols for monitoring high-risk residents, which resulted in the deficiency noted in the report.
Failure to Implement Effective Infection Control Measures
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment, leading to the potential spread of infection among residents, visitors, and the community. Three residents were affected by this deficiency, as the facility did not assess their skin rashes, place them on contact precautions, or notify a physician about ineffective treatments. Resident 1 was observed with red, raised scaly rashes on her lower legs and had severe cognitive impairment, requiring assistance with daily activities. Resident 3, who had diabetes and other health issues, was seen with red, raised, scaly rashes and burrowing on his body, indicating a possible scabies infestation. Resident 4, also with severe cognitive impairment, had similar rashes and was observed scratching continuously. The facility's Director of Nursing (DON) admitted that the staff had not reassessed Resident 3's condition after suspecting an allergic reaction, leading to a delay in effective treatment. The DON also confirmed that the nursing staff failed to identify Resident 4's rash, resulting in a delay in care and worsening of the condition. The facility's policy on scabies prevention and management was not followed, as residents with undiagnosed rashes were not placed on contact isolation, and there was no confirmation of scabies diagnosis through skin scrapings. The dermatologist's notes for Residents 3 and 4 indicated the presence of erythematous eczematous patches, linear burrows, and scabietic nodules, suggesting a scabies infestation. Despite these findings, the facility did not take appropriate measures to prevent the spread of infection. The lack of timely assessment, communication with physicians, and adherence to infection control policies contributed to the deficiency, putting the health and safety of residents and others at risk.
Failure to Prevent G Tube Dislodgement and Timely Hospital Transfer
Penalty
Summary
The facility failed to meet professional standards of quality care for a resident with a Gastrostomy Tube (G Tube) by not ensuring the use of an abdominal binder to prevent frequent dislodgement of the tube. Despite a care plan being initiated to use an abdominal binder, it was not consistently applied, leading to multiple dislodgements and unnecessary transfers to a General Acute Care Hospital (GACH). Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON), confirmed the oversight and acknowledged that the use of an abdominal binder could have prevented these incidents. Additionally, the facility did not transfer the resident to the hospital in a timely manner after the G Tube was dislodged. There was a significant delay between the identification of the G Tube malfunction and the actual transfer to the hospital, which could have resulted in malnutrition and dehydration for the resident who relied on the G Tube for nutrition and hydration. The ADON admitted that the physician should have been notified sooner, and the Medical Doctor (MD) emphasized the importance of timely hospital transfers to prevent health deterioration. The facility also lacked adequate training and policies regarding bowel impaction and abdominal assessments. The Director of Nursing (DON) admitted that abdominal assessments were conducted quarterly instead of the recommended three to four times a week, and there was no policy on constipation management. This lack of policy and training potentially contributed to the resident's fecal impaction and associated complications, as evidenced by the resident's repeated hospital visits for abdominal pain and bowel issues.
Failure to Address Resident Grievance Regarding Missing Walker
Penalty
Summary
The facility failed to promptly address a grievance reported by a resident, identified as Resident 6, regarding a missing personal walker. Resident 6, who was admitted with conditions including hemiplegia and major depressive disorder, reported that upon readmission from the hospital, her walker, which contained personal documents and blank checks, was missing. Despite informing the nursing staff, no grievance form was initiated or completed, and there were no nursing or social services notes documenting the resident's report of the missing walker. Interviews with facility staff revealed a lack of action in addressing the grievance. The Licensed Vocational Nurse (LVN) acknowledged being informed by Resident 6 about the missing walker. The Social Services Director (SSD) was aware of the report but had not initiated a theft and loss report, as she was waiting for confirmation from the rehabilitation department regarding the walker. The SSD also stated that a grievance form was not completed, and she did not document the resident's report. The Director of Nursing (DON) indicated that any theft and loss report should be investigated promptly and that a grievance and theft and loss report should have been initiated upon the resident's report. The facility's policies and procedures for grievances and theft and loss were not followed. The grievance policy required that any grievance or complaint be documented and investigated without fear of reprisal. The theft and loss policy mandated immediate investigation and documentation of missing property reports. However, these procedures were not adhered to, as evidenced by the lack of documentation and investigation into Resident 6's missing walker, resulting in a violation of the resident's right to have grievances addressed.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to effectively manage a resident's pain by not adhering to the physician's orders for pain management. Resident 2, who was admitted with a diagnosis of malignant neoplasm of the stomach, muscle weakness, and dysphagia, was prescribed Norco to be administered every six hours as needed for moderate to severe pain. Despite the physician's orders and the resident's intact cognitive skills, the facility did not administer the medication as required. The resident reported experiencing severe pain, rated at 8/10, and stated that the nurses were not administering the pain medication on time, which hindered his rehabilitation therapy. The medication administration records (MAR) for September showed that the resident's pain was assessed at a level of 8/10 on two occasions, but no interventions were documented, and Norco was not administered during the night shifts on those dates. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the licensed nurse should have provided interventions according to the physician's order when the resident reported severe pain. The facility's policy on pain management required the administration of pain medication as ordered and documentation of the resident's pain level and response to interventions, which was not followed in this case.
Failure to Document Resident's Death
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically by not implementing the facility's policy and procedures titled 'Death of a Resident.' This deficiency was identified for one of the three sampled residents, who was admitted with diagnoses including hypertension, diabetes mellitus, and dementia. The resident was on hospice care and passed away at 9:48 a.m. on the specified date. Upon review of the resident's medical records, it was found that there were no nurse's notes documenting the resident's death. The Director of Nursing confirmed the absence of documentation and acknowledged that there should have been a complete record of what transpired on the day of the resident's death. The facility's policy required that all documentation related to the resident's death, including the official pronouncement of death and communications with the family and relevant agencies, be maintained in the medical record, which was not adhered to in this case.
Failure to Educate Visitor on PPE Use for COVID-19 Precautions
Penalty
Summary
The facility failed to adhere to its infection control policy and procedure by not providing education about transmission-based precautions and not offering personal protective equipment (PPE) to a visitor of a resident who was under droplet precautions due to exposure to COVID-19. The resident, who had a history of hemiplegia, hemiparesis, chronic obstructive pulmonary disease, and type II diabetes mellitus, was observed in a room with droplet precaution signage. However, the resident's family member was seen inside the room without wearing any PPE and stated that they were not informed about the need for PPE or the reasons for its use. Interviews with facility staff, including a Licensed Vocational Nurse and the Infection Preventionist Nurse, confirmed that visitors should be educated on the importance of wearing PPE when visiting residents under isolation precautions. The facility's policy and procedures for managing COVID-19, which were reviewed prior to the incident, also indicated that visitors must wear a facemask and adhere to other precautionary measures. The failure to implement these measures had the potential to spread infection to residents, visitors, and the community.
Failure to Implement Dietary Recommendations Leads to Resident's Weight Loss
Penalty
Summary
The facility failed to update and implement a menu to meet the nutritional needs of a resident identified as being at risk for unplanned weight loss. The resident, who had diagnoses including prostate cancer, encephalopathy, and bile duct obstruction, was admitted to the facility and had a physician's order for a Registered Dietician (RD) consult. Despite the RD's recommendations to provide ice cream with meals and snacks to improve the resident's appetite, these recommendations were not carried out. As a result, the resident experienced significant weight loss of 5 pounds, which was 3% of his body weight in one week. The resident's weight loss was noted during a weight variance meeting, and it was acknowledged by the RD that the recommendations were not implemented. The Director of Nursing (DON) expressed concern about the resident not eating and emphasized the importance of following dietary recommendations to prevent significant weight loss. The facility's policy and procedures on evaluating weight and nutritional status were reviewed, indicating the need to maintain acceptable nutritional parameters through proper assessment and intervention, which were not adhered to in this case.
Failure to Administer Critical Cancer Medication
Penalty
Summary
The facility failed to implement its own policies and procedures by not ensuring the accurate administration of the medication Darolutamide for a resident with prostate cancer. The resident was admitted with diagnoses including prostate cancer, encephalopathy, and obstruction of the bile duct. A physician's order was in place for Darolutamide to be administered twice daily, but the medication was not delivered or administered due to its high cost and lack of insurance coverage. There was no documented evidence that the physician was notified of the missing medication. Interviews with staff revealed a lack of communication and documentation regarding the missing medication. A Licensed Vocational Nurse (LVN) admitted to informing the attending physician but could not provide evidence of this communication. The oncologist was not notified, and another LVN assumed the first LVN had contacted the physician based on overheard conversations. The Pharmacy Consultant emphasized the importance of taking the medication daily to slow disease progression, and the Director of Nursing acknowledged the failure to provide the necessary medication. The facility's policy on medication administration was not followed, as confirmed by the Director of Nursing and the Administrator. The Administrator admitted that the facility should have ensured the availability of all medications upon the resident's admission. The attending physician was unaware of the situation, highlighting a breakdown in communication and adherence to the facility's procedures.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to ensure that a licensed nurse notified the physician about a change of condition (COC) for a resident, which is a significant deficiency. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, exhibited symptoms of abdominal distention and inconsistent bowel movements. Despite these symptoms being reported by a Certified Nursing Assistant (CNA) to a Licensed Vocational Nurse (LVN), the LVN did not notify the physician or initiate a COC form, which was required by the facility's policy. The resident had a history of abdominal distention due to alcohol-induced chronic pancreatitis, and the facility's care plan required changes in bowel and bladder status to be reported to a medical doctor. On the day of the incident, the resident was found unresponsive during dinner service, and despite efforts to perform CPR, the resident was pronounced dead shortly after. Interviews with staff revealed that the resident had refused to eat and had not had a bowel movement, which were signs that should have prompted immediate medical attention. The Director of Nursing (DON) acknowledged that the resident's assessments should have included daily abdominal girth measurements to detect changes. The facility's policy on Change of Condition Notification required prompt communication with the resident's physician and family in the event of significant changes in the resident's condition. The failure to adhere to this policy potentially contributed to the resident's decline and subsequent death.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and preventive measures for a resident assessed as high risk for falls, resulting in multiple falls and injuries. The resident, admitted with a history of repeated falls and unspecified psychosis, was identified as high risk for falls in their care plan. Despite this, the facility did not provide a full-time 1:1 sitter as outlined in the care plan, leading to the resident experiencing falls on several occasions, including incidents on January 25, April 11, April 28, and May 7, 2024. These falls resulted in injuries such as a dislocated finger, a fractured ulna, and a hematoma on the forehead. The care plan for the resident included interventions such as maintaining a safe environment, frequent visual checks, and providing a 1:1 sitter as necessary. However, the facility did not consistently implement these interventions, particularly the provision of a 1:1 sitter, which was only arranged after the resident's fall on May 7, 2024. The facility's failure to evaluate the effectiveness of the care plan interventions after the resident's initial fall on January 25, 2024, and to consider alternative interventions, contributed to the resident's subsequent falls and injuries. Interviews with facility staff, including a CNA and the Director of Nursing, revealed that the resident was not provided with a full-time sitter before the most recent fall on May 7, 2024. The staff acknowledged that the care plan interventions were ineffective in preventing the resident's falls. The facility's policy and procedures for sitters and fall prevention were not adequately followed, resulting in the resident's repeated falls and injuries.
Failure to Maintain Clean and Pest-Free Staff Breakroom
Penalty
Summary
The facility failed to maintain a safe and functional area to prevent the infestation of roaches and provide a clean environment in the staff's breakroom. During an observation and interview with the Maintenance Supervisor, multiple dead roaches were found under the sink in the staff's breakroom on the lower level. The ground was dirty, and the floors were dusty with dead roaches and baits under the sink. The Maintenance Supervisor acknowledged that the roaches had been dead for a long time and had not been cleaned. The Administrator confirmed that the Maintenance and Housekeeping staff would clean the breakroom and remove the dead roaches. The facility's policies and procedures for pest control and housekeeping, reviewed on 1/26/2024, indicated that the facility should be free of pests and maintained in a clean and sanitary condition to promote health and safety.
Failure to Promote Dignity and Respect for Residents
Penalty
Summary
The facility failed to promote dignity and respect for two residents by not conducting a personal property inventory upon admission for one resident and allowing staff to speak in a language not understood by another resident in their presence. Resident 200, who was admitted with several medical conditions including supra ventricular tachycardia, muscle weakness, cognitive communication deficit, and end-stage renal disease, reported missing belongings and dentures. The facility did not complete a personal property inventory upon Resident 200's admission, leading to confusion and distress for the resident. The Social Worker later attempted to rectify the situation by reviewing the belongings list with Resident 200, but discrepancies remained, particularly regarding the amount of cash and the delay in providing dentures, which affected the resident's ability to eat properly. Interviews with facility staff confirmed the failure to follow proper procedures for documenting and securing residents' belongings upon admission, as outlined in the facility's policy and procedures. The Assistant Director of Nursing acknowledged that failing to complete a resident's belongings list upon admission was a significant oversight that could lead to the loss of irreplaceable valuables and make the facility liable for any missing items. Resident 21, who was admitted with cellulitis and chronic kidney disease, complained that staff spoke in a language not understood by the resident in their presence. This made Resident 21 feel excluded and angry, as they believed the staff might be talking about them. The Assistant Director of Nursing confirmed that the facility's policy required staff to speak only in English in the presence of residents unless communicating with a resident who does not speak English. The facility's policy aimed to maintain the dignity and well-being of residents by ensuring clear and inclusive communication.
Failure to Ensure Comfortable Sound Levels at Night
Penalty
Summary
The facility failed to ensure comfortable sound levels at night for three residents, compromising their ability to sleep undisturbed. Resident 52, who has medical diagnoses including atrial fibrillation, subdural hemorrhage, and hypertension, reported high noise levels at night, requiring them to close the door to sleep. Resident 246, diagnosed with generalized muscle weakness, schizophrenia, and hypertension, also complained about high noise levels both during the day and night. Resident 83, with bipolar disorder, depression, and generalized muscle weakness, stated that the night shift was very loud, making it difficult to sleep due to staff opening closet doors loudly and causing window shutters to make noise due to a breeze. Interviews with staff confirmed the issue, with a Certified Nursing Assistant stating that lights should be off and noise minimized during the night shift to allow residents to sleep. The Director of Nursing also acknowledged that noise levels should be minimal, especially at the nursing station, to ensure residents can sleep. The facility's policies and procedures emphasize providing a safe, clean, comfortable, and homelike environment with comfortable noise levels, but these were not adhered to, leading to the deficiency.
Failure to Conduct Timely PASRR for Residents
Penalty
Summary
The facility failed to conduct Pre-Admission Screening Resident Review (PASRR) for two residents, leading to potential inappropriate care and services. Resident 33 was admitted with diagnoses including major depressive disorder, anxiety disorder, and PTSD. A review of Resident 33's PASRR level 1 screening revealed that question 27, which pertains to suspected mental illness, was left blank. The Assistant Director of Nursing (ADON) acknowledged that the incomplete PASRR could result in the resident not receiving the appropriate level of care for their behavioral needs. The facility's policy mandates that any incomplete PASRRs be completed the same day, but this was not adhered to in Resident 33's case. The Administrator also noted that only one staff member, a Registered Nurse, had access to the PASRR system, which contributed to the oversight. The facility's policy emphasizes the importance of PASRR in ensuring comprehensive and person-centered care for residents with mental health needs. Resident 60 was admitted with diagnoses including unspecified psychosis, dementia, and cognitive communication deficit. A review of Resident 60's PASRR indicated that it was not initiated until several months after admission. The ADON confirmed that the delayed PASRR could lead to inappropriate care, potentially resulting in harm to the resident. The facility's policy requires that PASRRs be completed by midnight on the date of admission, but this was not followed for Resident 60. The care plan for Resident 60 highlighted the need to address concerns about confusion and the disease process, but the lack of a timely PASRR compromised the ability to provide appropriate care. The facility's failure to adhere to its own policies and procedures for PASRR completion was evident in both cases, leading to deficiencies in the care provided to these residents.
Failure to Properly Store and Label Food
Penalty
Summary
The facility failed to store and label food in accordance with professional standards and facility policy, which placed residents at risk for foodborne illnesses. During an initial tour of the kitchen, seven food items in the refrigerator were found with past expiration dates, and eight food items on the shelves had no expiration dates. The Dietary Supervisor (DS) acknowledged that it was the kitchen staff's responsibility to check for expired foods and discard them, and admitted that residents could get sick if they consumed expired foods. Additionally, the DS stated that she would remind the kitchen staff every morning to check for expired foods and discard them. Further observations revealed that the refrigerator used for residents' food brought from outside contained 15 food items that were not labeled or dated. The DS admitted that the refrigerator in the staff lounge was the only one used for storing residents' outside food and that she did not know how the staff identified which food belonged to the residents. The Maintenance Assistant (MA) confirmed that he was responsible for cleaning the refrigerator in the staff lounge every Thursday and acknowledged that consuming expired food could make residents or staff sick. A review of the facility's policies indicated that food brought in by visitors should be clearly labeled with the resident's name and date received, and stored in a designated refrigerator, which was not being followed.
Failure to Obtain Physician's Order for Resident's Out on Pass
Penalty
Summary
The facility failed to protect the rights of Resident 60 by not obtaining a physician's order for the resident to go out on pass. Despite Resident 60 having a doctor's order issued on 12/16/23 for a one-day pass, the facility did not secure a continuous order for subsequent passes. Resident 60, who has intact cognition and requires supervision and moderate assistance for mobility, complained about being denied the ability to go out on pass, which was corroborated by the resident's out on pass sign sheet showing multiple instances of leaving the facility without a current physician's order. Interviews with the Registered Nurse and the Director of Nursing revealed that the staff allowed Resident 60 to go out on pass without a physician's order due to the resident's threats to blow up the facility if not permitted to leave. The facility's policy requires a physician's order for a resident to go out on pass, which was not adhered to in this case. This failure to follow protocol potentially impacted Resident 60's psychosocial well-being and self-esteem.
Incomplete PASRR Assessment for Resident
Penalty
Summary
The facility failed to ensure a comprehensive assessment for pre-admission screening Resident Review (PASRR) for one of the sampled residents, Resident 33. The resident was admitted with medical diagnoses including major depressive disorder, anxiety disorder, and PTSD. A review of Resident 33's PASRR level 1 screening revealed that question 27, which pertains to suspected mental illness, was left blank. This incomplete assessment was confirmed during an interview with the Assistant Director of Nursing (ADON), who acknowledged that the blank question could lead to inadequate care for the resident's behavioral needs. The ADON stated that the PASRR is crucial for determining the mental capacity of the resident and ensuring their needs are met appropriately. The facility's policy mandates that any incomplete PASRRs must be completed the same day, but this was not adhered to in this case. During an interview with the Administrator (ADM), it was revealed that only one Registered Nurse had access to the PASRR system, and efforts were being made to grant access to more staff members. The facility's policy on PASRR, revised in 2018, emphasizes the importance of screening all applicants for mental illness and intellectual disability before admission. Additionally, the facility's policy on medical record completion, revised in 2012, states that no blank spaces should be left on forms. The failure to complete the PASRR accurately for Resident 33 had the potential to negatively affect the provision of necessary care and services for the resident.
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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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