Hale Nani Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 1677 Pensacola Street, Honolulu, Hawaii 96822
- CMS Provider Number
- 125011
- Inspections on file
- 27
- Latest survey
- May 1, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Hale Nani Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Multiple failures to maintain resident dignity and timely care were identified, including a resident left waiting over an hour for assistance to urinate despite documented mobility deficits, and two residents with indwelling urinary catheters whose drainage bags were left uncovered and visible from the hallway contrary to facility policy. During a Resident Council meeting, residents reported that certain CNAs did not consistently provide basic morning hygiene, ignored or delayed responses to call lights, and sometimes turned off call lights after learning a request involved incontinence care without returning, resulting in residents remaining soiled for extended periods and care being left for the next shift.
Staff failed to keep call systems within reach for three LTC residents who were incontinent and dependent on staff for ADLs, including residents with arthritis, bipolar disorder, chronic pain, stroke with one-sided impairment, and hemiplegia/hemiparesis. Surveyors observed call lights and call pads placed toward the head of the bed, behind the bed on a light fixture, or hanging on the wall above the bed, all out of the residents’ reach during multiple observations. These practices did not follow the facility’s policy requiring call lights to be within reach and accessible while residents are in bed.
Multiple rooms on one unit were found with environmental deficiencies, including broken and unsecured electrical outlets, damaged and stained walls and ceilings, improvised extensions on light cords using a plastic bag and a washcloth, dripping and constantly running sink faucets with discolored grout, and a strong urine odor in one room. A review of work orders and an interview with the Facilities Director showed that only two work orders had been submitted for this unit, both generated after surveyor observations, indicating that unit staff had not routinely initiated maintenance requests for these conditions.
The facility failed to adequately inform and assist multiple residents with Advance Health Care Directives (AHCDs). One resident requested an AHCD form but received no documented follow-up or assistance, and this issue was not addressed in later interdisciplinary team meetings. Another resident had a Five Wishes AHCD document on file that lacked required witness signatures, despite clear instructions that witnessing was necessary for validity. A third resident initially declined an AHCD, but the facility did not periodically revisit the discussion, and the resident later reported that no one had discussed AHCDs with him and expressed a desire to complete one.
Surveyors observed that the lab specimen refrigerator had brown stains on the door and bottom shelves and multiple small dead bugs on the door shelf, demonstrating that staff failed to maintain a clean environment in an area used for specimen storage. The Infection Prevention Nurse acknowledged the refrigerator was dirty.
Surveyors found that the facility failed to develop and maintain comprehensive care plans for two residents, one receiving an anticoagulant and psychotropic meds for vascular dementia with agitation, and another with a history of sacral pressure ulcers and a high Braden risk score. The first resident’s care plan did not address anticoagulant use or dementia-related care despite active orders and facility policy requiring individualized dementia care planning. The second resident’s care plan lacked any pressure ulcer prevention or management interventions, even though prior sacral ulcers had healed with documented preventive measures in place and the ulcer later reopened; staff confirmed the resident’s high risk and the absence of an active pressure injury prevention care plan during that time.
The facility failed to revise care plans for two residents to reflect current care needs and behaviors. One resident with multiple cardiac and pulmonary conditions, including HF, AFib, and COPD, reported frequent self-connection to a bedside pacemaker monitoring device known to staff, yet the comprehensive care plan contained no interventions or instructions regarding this monitoring. Another resident with CHF, alcohol-induced dementia, MRSA carrier status, and psychotic disorder was repeatedly observed with large urine puddles on the bedroom floor, and an RN stated that this resident urinated on the floor regularly and therefore had a private room, but the active care plan only addressed scheduled toileting and episodes of voiding in a trash can, without documenting the ongoing behavior of urinating on the floor.
A deficiency was identified in which three residents did not receive care according to professional standards and their care plans. One resident with severe cognitive impairment and multiple comorbidities experienced an acute change in condition, but staff did not perform or document ongoing neuro checks or vital sign and O2 monitoring after the initial assessment and were unable to initiate ordered IV fluids. Another resident with CHF, alcohol-induced dementia, and behavioral issues was repeatedly found with large puddles of urine on the floor, while behavior and continence documentation did not capture these episodes, and no scheduled toileting or bladder program was implemented despite assessments and facility policy indicating the need. A third resident on hospice with open shin lesions had physician orders for every-other-day and PRN wound dressings, yet was observed on multiple occasions without a dressing in place, even though the TAR reflected that treatments had been completed and nursing staff could not explain the discrepancy.
A resident with limited mobility, multiple chronic conditions, and a history of a recent unwitnessed fall was care planned as a one-person assist for ambulation using a device. On observation, the resident was moving rapidly down the hall with a front-wheel walker, calling out to staff, wearing an open gown with no underwear, no foot coverings, and with a left lower leg/foot dressing coming undone and visibly soaked with blood. The only staff present, an RN at the med cart, repeatedly instructed the resident to return to her room but did not stop to provide hands-on assistance or ensure safe return, despite the documented requirement for one-person assist. The unit manager confirmed that the resident required one-person assistance and that the RN should have helped her back to her room.
A resident receiving short-term rehab with an indwelling urinary catheter was observed in a wheelchair with the catheter drainage bag hung under the seat and touching the floor, despite facility documentation requirements that staff verify each shift that privacy bags are in place and drainage bags are not on the floor. An RN confirmed that catheter bags are not supposed to touch the floor, indicating a failure to follow established catheter care and infection control practices.
A resident with severe cognitive impairment, dysphagia, and total dependence for eating experienced a marked decline in PO intake and an 8.1% weight loss in one month. The RD documented poor meal intake (0–25% for most meals), reduced fluid intake, identified the resident as at risk for malnutrition, and recommended a reweigh and weekly weights. Despite facility policy requiring reweigh and physician notification for significant weight variance, staff did not perform a reweigh, did not obtain a November weight, and did not document provider notification. The resident was later hospitalized with poor PO intake noted and subsequently required PEG placement.
A resident receiving O2 at 3 L via nasal cannula was observed in bed with the concentrator running and the cannula on her face, but the O2 tubing was disconnected from the concentrator and lying on the floor. The resident’s SpO2 was 85% at the time of discovery, and she became upset about the situation. An RN acknowledged that the tubing was not connected, suggested it might have been dislodged when staff assisted the resident, and confirmed that staff are expected to verify tubing placement before leaving the resident.
A resident with an AVF in the right arm for hemodialysis had a physician order and care plan directing staff to keep the post-hemodialysis compression bandage on no longer than a specified number of hours and to assess and remove the dressing as ordered after each HD session. Documentation showed the resident returned from HD with the AVF dressing intact, clean, and dry and without bleeding or pain, yet the next morning the resident reported that staff had not removed the dressing, and observation confirmed the dressing was still in place. The DON and IDON verified the time-limited AVF dressing order and could not explain why the dressing had not been removed as required.
A physician’s post-hospitalization progress note for a resident who had recently been treated for severe sepsis, severe hypernatremia, constipation, and had a PEG tube placed failed to document the hospitalization, the reasons for admission, the hospital diagnoses, or the new PEG and tube-feeding status. Instead, the note contained a general review of systems and physical exam with an assessment of CVA and constipation, without reflecting the recent acute conditions or significant change in nutritional route.
The facility failed to provide sufficient CNA staffing on a high‑census unit, resulting in only three to four CNAs caring for 49 residents while staff were floated to lower‑census units. A resident and multiple staff reported that showers were often replaced with bed baths due to inadequate staffing and the need to keep CNAs on the unit to answer call lights. Several residents described waiting 45–60 minutes for call light responses, including one who remained incontinent for several hours and another who slept in urine. Residents also reported rushed and incomplete hygiene care and noted that overworked staff argued about assignments and sometimes limited help to their own areas.
The facility failed to follow safe medication administration practices by leaving medications unattended at the bedside and not directly observing residents taking them, even though no residents were authorized to self-administer. In multiple instances, an RN and an LPN placed cups of medications on bedside surfaces and left, or medications were found unattended, including for a cognitively intact hospice patient and a resident with ESRD, as well as a resident with severe recurrent MDD with psychotic features and a history of suicidal ideation. Staff acknowledged leaving medications at the bedside as a routine way to encourage ingestion, despite facility policies requiring medications to remain under direct observation during passes and prohibiting unauthorized bedside storage or self-administration.
A resident’s monthly medication regimen reviews (MRRs) were not properly documented, as the facility could not produce the MRR that contained a pharmacist’s recommendation about fluid restriction, and there was no evidence that the attending physician reviewed or responded to pharmacist recommendations for gradual dose reductions of Abilify, Trazodone, and Vilazodone. The pharmacist repeated the same recommendations in a subsequent MRR, and the DON in training confirmed both the missing MRR and the lack of physician documentation, contrary to facility policy requiring timely review and response to pharmacist-reported irregularities.
A resident receiving multiple psychotropic medications, including an antipsychotic and antidepressants for depression and anxiety, did not have required behavior monitoring documented to support the ongoing use and effectiveness of these drugs. The DON in training reported that behavior monitoring should be recorded on the treatment administration record but could not locate any such documentation for this resident. This was inconsistent with the facility’s psychotropic medication policy, which requires monitoring and documentation of the resident’s response to demonstrate that the medications are appropriate and beneficial.
A resident with hemiplegia and hemiparesis following a cerebral infarction was given another patient’s medications when a nurse failed to follow established medication administration procedures. The resident’s EHR documented that the Unit Manager was notified of a med error and that the resident received multiple medications not prescribed for him, including Tylenol, furosemide, spironolactone, olanzapine, Entresto, Brilinta, metoprolol, aspirin, ticagrelor, venlafaxine, and gabapentin. The DON stated that RNs are trained to use two identifiers and follow the facility’s Medication Administration policy, which requires verifying the resident by photo in the MAR and matching the medication source to the MAR for name, drug, dose, route, and time, but these steps were not followed in this instance.
Surveyors found that a treatment cart on one unit had a broken lock, allowing unrestricted access to medications and medical supplies, and that a medication cart in a hallway was left unlocked and unsecured while an RN was away administering meds to a resident. Both the treatment nurse and the RN acknowledged that carts should be locked when not in use, and the DON confirmed that medication carts must always be secured. Facility policy stated that all drugs and biologicals must be stored in locked compartments, but the observed practices did not comply with this requirement.
A resident with a documented No Added Salt (NAS) diet and clear instructions for no sauce, gravy, or chicken skin was repeatedly served meals that did not follow these specifications. During one observed meal, the resident received chicken with skin and gravy despite the diet card prohibiting these items, and the resident reported that the previous evening’s dinner plate also contained a large amount of gravy. The resident stated they did not report the issue to staff because they did not want to complain and feared their meal would be delayed, demonstrating that the facility did not consistently honor the resident’s documented food preferences and restrictions.
Surveyors found that kitchen sanitation buckets contained sanitizer solutions that tested below the required 150–400 PPM when checked with Hydrion QT-40 test strips, and a dietary aide was not following the manufacturer’s specified testing procedure. Further review with the dietary manager showed that only older training records on preparing and using sanitation solutions were available, with no accessible documentation of staff training for the more recent period.
The facility failed to consistently implement its infection prevention and control program, including proper use of contact precautions, Enhanced Barrier Precautions (EBP), and hand hygiene. A resident with C. difficile was cared for by staff and visited by a visitor who did not follow required gown, glove, and soap-and-water handwashing protocols, despite posted signage and facility policy. During meal service and medication administration, a CNA and an RN moved between residents and care tasks without performing hand hygiene between contacts or between glove changes. Two CNAs provided bathing and hygiene care to a resident under EBP without wearing required gowns, and in another EBP room, a resident handled a roommate’s trash bin and urine-filled urinal, discarded trash in the soiled utility room, and returned the urinal without being prompted by an LPN to perform hand hygiene afterward.
Surveyors observed multiple failures in infection prevention, including staff not performing hand hygiene between resident care tasks, improper doffing of PPE, and incorrect storage and changing of respiratory equipment. Additionally, required Covid-19 testing was not completed within policy timeframes for residents exposed to positive cases, and staff did not consistently use appropriate PPE when assisting residents on contact precautions.
The facility did not provide required written transfer or discharge notifications to two residents, their representatives, or the Ombudsman, and used forms missing the Ombudsman's address and appeal rights information. Staff were unaware of the notification requirements, and documentation was lacking for multiple hospitalizations.
Two residents with significant mobility limitations did not receive consistent range of motion (ROM) and splinting interventions as ordered in their care plans. Observations and record reviews showed that required ROM exercises and splint applications were missed on multiple occasions, and staff interviews confirmed that these services were not provided at the prescribed frequency due to staffing shortages.
Two residents were placed at increased risk of accidents due to inadequate supervision and unsafe environmental conditions. One resident with dementia and mobility issues was repeatedly observed wandering unsupervised, despite care plan interventions requiring close monitoring. Another resident who smokes was escorted to a designated smoking area that lacked a fire extinguisher and had improper disposal of cigarette butts, contrary to facility policy. Staff interviews confirmed awareness of these deficiencies.
Two residents experienced inadequate pain management due to staff failing to assess and monitor pain appropriately, including not pre-medicating a non-verbal resident before PROM exercises and not using effective communication tools for a resident whose preferred language was Vietnamese. Staff did not follow care plan interventions or use available pain assessment resources, resulting in unaddressed pain and discomfort.
Three residents and a representative did not understand the Binding Arbitration Agreement they signed during admission, as they either did not recall signing it or were unaware of its implications, despite facility policy requiring clear explanation and acknowledgment of understanding.
Staff failed to maintain resident dignity during mealtime assistance by standing over residents instead of sitting at eye level, leaving residents unattended, and engaging in unrelated conversations while assisting with meals. CNAs and an LPN confirmed awareness of proper procedures, and the DON stated that staff are expected to sit beside residents to promote comfort and communication.
Two residents with severe cognitive impairment were not supported in the care planning process by their representatives, as required. One resident's representative was not invited to participate in the care plan meeting, and for another, the required quarterly care planning meeting was missed, leaving the family representative uninvolved. Staff confirmed the lack of notification and documentation for representative participation.
A resident with moderate cognitive impairment was found with multiple medications left at her bedside for self-administration, despite no documented assessment confirming her ability to do so. Nursing staff acknowledged the error, and the DON confirmed that the resident was not clinically appropriate for self-administration and lacked the required assessment.
A resident who was fully dependent on staff and unable to bend her knees was not provided with a shower gurney, resulting in her receiving only bed baths despite her preference for weekly showers. Staff confirmed that no shower gurneys were available and that only one mechanical lift was present on the floor for nine residents who required it, with the lift sometimes being unavailable due to use on other floors.
A resident who was fully dependent on staff for personal hygiene expressed a preference for showers, which was communicated by her family and noted as important in her assessment. Despite this, staff were unaware of her preference, and she was only provided bed baths according to the posted schedule. The DON confirmed that the facility had not identified or documented the resident's bathing choice, and necessary equipment to support her preference was not secured.
Two residents who managed their own trust accounts did not receive required quarterly personal fund statements directly from the facility, despite being cognitively intact and designated as their own responsible persons. Statements were sent to off-site addresses or family members, and there was no documentation or tracking to confirm delivery to the residents, leaving them unaware of their account balances.
A documentation station used by CNAs and RNAs was left open and accessible in a busy hallway, displaying a resident's personal and clinical information. Staff interviews confirmed the station should have been closed to protect privacy and comply with HIPAA, in line with facility policy.
Two residents were found in unclean conditions, with one using dirty fall mats and another sitting beneath a stained ceiling tile. Staff were unaware of the issues and could not confirm when cleaning or maintenance had last occurred.
Two residents did not receive accurate assessments: one with severe cognitive impairment and a history of wandering was not coded for wandering behaviors despite repeated unsupervised ambulation, and another who speaks only Vietnamese was marked as rarely understood after a BIMS assessment was attempted in the wrong language, leading to unmet needs.
The facility did not develop or implement complete, individualized care plans for several residents, including one with incontinence and skin breakdown, another needing interpreter services, and a third requiring trauma-informed care. Staff were observed using improper peri-care techniques, and care plans did not reflect residents' specific communication or psychosocial needs, resulting in unmet needs and a decline in quality of life.
A resident with end stage renal disease returned from dialysis with a pressure dressing on the access site, but the facility did not revise the care plan to include interventions for care of the site or removal of the dressing. Nursing staff demonstrated inconsistent practices regarding responsibility and timing for removing the dressing, and the Director of Nursing confirmed there was no established protocol in place. This resulted in the resident retaining the pressure dressing for an extended period without appropriate assessment or intervention.
Two residents with limited English proficiency were not provided with effective communication supports, such as accessible communication boards or interpreter services, despite facility policy and care plans indicating these needs. Staff were unaware of available translation services and relied mainly on gestures, leaving residents unable to fully communicate their needs or express choices.
A resident returned from dialysis with a pressure dressing on their fistula, which was not removed for an extended period. The dressing was left on overnight and reapplied by the night shift due to bleeding, but was not reassessed or removed until late the next morning. The DON confirmed that the dressing should have been removed within a few hours and the site checked regularly, but this did not occur due to lack of communication and assessment.
A resident with a history of PTSD and other mental health diagnoses was not properly screened for trauma upon admission, and required assessments and checklists were either delayed or inadequately completed. Only the Social Services Director had completed trauma-informed care training, leaving other social services staff untrained at the time of the survey.
A resident with dementia and a history of stroke was repeatedly observed wandering unsupervised, taking food from others, and displaying aggressive behaviors. Staff and other residents reported ongoing distress, and interviews revealed that the underlying causes of the behaviors were not clearly identified or addressed in the care plan. Psychiatric referrals were delayed, and supervision was insufficient, resulting in continued behavioral issues affecting the unit.
A nurse administered scheduled medications, including antihypertensives with hold parameters, to a resident more than two hours early without verifying vital signs, and inaccurately documented the administration time. Additionally, a medication cart audit revealed incomplete narcotic count sheet documentation, with missing signatures and verification fields, contrary to facility policy.
A resident with multiple diagnoses did not have timely follow-up or proper documentation regarding pharmacist recommendations for medication changes, including a suggested GDR for Trazadone and monitoring after starting Lexapro. Required reviews and psychotropic meeting documentation were missing, indicating a lapse in the facility's medication management process.
Surveyors identified that medications were not properly stored, labeled, or administered according to professional standards. A resident was left unsupervised with medication, and staff failed to observe medication administration as required. Additionally, discontinued and unlabelled medications, including controlled substances, were found improperly stored in the medication cart, and not removed or disposed of per facility policy.
A resident with multiple chronic conditions was not provided with preferred food and drink options despite repeated requests and a diet waiver, resulting in the resident refusing facility meals and experiencing feelings of malnourishment and weakness. Staff interviews confirmed ongoing miscommunication between nursing and kitchen staff regarding the resident's dietary preferences.
Staff failed to consistently label and discard resident food items according to facility policy, with one container missing a date and another kept beyond the recommended three-day period. An RNA, LPN, and RN confirmed the improper storage, and a kitchen staff member clarified that nursing staff are responsible for labeling and discarding resident food. The facility lacked a policy specifying the maximum storage duration for these items.
A nurse administered multiple medications to a resident more than two hours before the scheduled time and documented them as given on time, contrary to facility policy and accepted nursing standards. The DON confirmed that medications should not be given or documented outside the one-hour window, and the documentation was found to be inaccurate and misleading.
Failure to Maintain Resident Dignity, Privacy, and Timely Response to Care Needs
Penalty
Summary
The deficiency involves multiple failures to honor residents’ rights to dignity, respect, and timely assistance with care needs. One resident reported that after an activities session she informed staff she needed to urinate but was told to wait; staff did not return for over an hour, and it was the next shift that ultimately assisted her. She stated she did not feel treated with respect or dignity. Her electronic health record showed diagnoses including diabetes, chronic kidney disease, chronic pain, borderline personality, and schizoaffective disorder, and her care plan documented mobility and self-performance deficits due to significant muscle weakness and debility. Surveyors also observed two residents with indwelling urinary catheters whose drainage bags were positioned facing the bedroom door and visible from the hallway without privacy bags in place, despite multiple observations over several hours. The RN and DON both confirmed that catheter drainage bags should always be covered with privacy bags, and facility policy on catheter care and promoting/maintaining resident dignity required catheter bags to be covered at all times while in use and that staff maintain resident dignity and respect resident rights. During a Resident Council meeting, residents reported that certain CNAs did not consistently respond to care needs, did not provide basic morning hygiene such as wiping faces and hands, and sometimes turned off call lights after asking if the need involved urine or bowel movement without returning to provide incontinence care, leaving care for the next shift. Two residents reported remaining in their bowel movements for about one and a half hours after lunch when staff did not return after call lights were activated, and one resident stated staff respond more quickly when the bathroom call light is used.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves staff failing to ensure that resident call systems were within reach for multiple residents who were dependent on staff for activities of daily living. One resident with arthritis, bipolar disorder, chronic pain, and total bowel and bladder incontinence was observed in bed with her call light cord positioned toward the head of the bed and out of her reach; when asked, she confirmed she could not reach it and requested that it be moved closer. Another resident with a history of stroke and one-sided impairment, who was incontinent and dependent on staff for ADLs, was observed lying in bed without access to the gray call pad, which was hanging on a light fixture behind the bed; he stated he was able to use the call pad, but it was not placed where he could reach it until a CNA later repositioned it. A third resident with hemiplegia and hemiparesis affecting the left non-dominant side, impaired left upper extremity, and functional limitation in upper extremity range of motion was repeatedly observed lying comfortably in bed while the call light was left hanging on the wall above the bed and out of reach. This resident was able to communicate verbally and move the right upper extremity, but the call light remained out of reach during multiple observations on different days and times. Review of the facility’s policy titled “Call Light: Accessibility and Response” showed that staff were required to ensure the call light was within reach of the resident and accessible while the resident was in bed, which was not followed in these instances.
Failure to Maintain Homelike and Well-Maintained Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the Pensacola 1 unit, as evidenced by multiple environmental deficiencies observed in six resident rooms. In one room, a wall clock was broken with a large piece missing and several white patches were visible on the wall. Another room had multiple large brown marks of unknown substance on the wall that were immediately visible upon entry. A separate room had a loud, constant buzzing noise whenever the bathroom light was turned on. Additional observations included several visible water marks on a ceiling, a broken electrical plug plate, and a heavily damaged wall behind a bed. Other rooms showed further environmental issues, including a wall light over a bed that had a cord extended with a plastic bag so the resident could reach it, and an electrical outlet at the head-of-bed wall that was not secure and was visibly coming out of the wall. One room had a dripping sink faucet and very discolored grout around the sink, while another had a strong smell of urine. Yet another room had a sink faucet that was constantly running, and one bed area had a washcloth attached to the light cord to extend its reach and six large screws or hooks in the wall. Interview with the Facilities Director revealed that unit staff were expected to complete work orders for needed repairs, but only two open work orders existed for this unit, both related to issues reported during the survey, indicating that routine work orders had not been submitted by unit staff for the observed problems.
Failure to Inform and Assist Residents With Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to properly inform and assist residents with formulating Advance Health Care Directives (AHCDs) and to ensure that existing AHCD documents were validly executed. For one resident (R17), the EHR showed that AHCD information was discussed and the resident requested a blank AHCD form on 04/14/25. However, there was no subsequent documentation that the resident completed an AHCD or that the facility provided follow-up assistance after that date. The Social Services Assistant (SSA) confirmed there was no follow-up documentation, and the most recent interdisciplinary team meeting record for this resident contained no reference to AHCD follow-up. For another resident (R170), the facility obtained a completed Five Wishes document intended to serve as an AHCD, but the document lacked required witness signatures, despite instructions on the form stating it must be signed and witnessed as directed to be legal and valid. The SSA confirmed the absence of witness signatures. For a third resident (R153), the EHR showed that AHCD information was last discussed on 12/10/24, at which time the resident declined to formulate an AHCD. There was no evidence that the facility revisited the discussion or reoffered assistance after that date. In a subsequent interview, this resident reported that the facility had not discussed an AHCD with him and stated he would like to complete one.
Unclean Lab Specimen Refrigerator Compromises Environmental Cleanliness
Penalty
Summary
Surveyors identified a deficiency related to the resident’s right to a safe, clean, comfortable, and homelike environment when the lab specimen refrigerator was found to be unclean. During an observation of the refrigerator, brown stains were noted on the door shelf and bottom shelf, and multiple small dead bugs were present on the door shelf. In a subsequent interview, the Infection Prevention Nurse acknowledged that the lab specimen refrigerator was dirty. These conditions demonstrated that the facility failed to maintain a clean environment in the area where lab specimens are stored.
Failure to Develop Comprehensive Care Plans for Anticoagulant Use, Dementia, and Pressure Ulcer Prevention
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive, individualized care plans addressing all identified needs for two residents. For one resident with vascular dementia and agitation, record review showed an active order for Eliquis 2.5 mg twice daily with instructions to monitor for adverse reactions, but the resident’s care plan did not address the use of this anticoagulant medication. During interview, the MDS RN confirmed that the anticoagulant should have been included in the care plan. The same resident had diagnoses including vascular dementia with agitation and was prescribed psychotropic medications, yet the care plan did not include dementia-related care. The MDS RN verified that dementia care should have been incorporated, despite the facility’s own dementia policy requiring individualized care plans that consider symptoms, disease progression, and co-existing conditions. The second resident had a history of sacral/buttocks pressure ulcers that had previously healed, with APRN documentation that preventive interventions such as scheduled repositioning, pressure-relieving devices, incontinence care, and protective dressings remained in place. A subsequent wound clinic note documented that the prior sacral ulcer site had broken down again, with fat layer exposed, and attributed contributing factors including moisture-associated skin damage and trauma from a shower chair. The resident reported that the wound may have reopened due to prolonged time in a wheelchair without repositioning assistance and stated that staff did not consistently assist with repositioning every two hours as recommended. Review of the care plan revealed no documented interventions for pressure ulcer prevention or management, despite a Braden Scale score of 11 indicating high risk. Nursing staff confirmed the resident was at high risk for pressure ulcer development and that the care plan did not include pressure ulcer prevention interventions, and the MDS RN reported that the pressure injury care plan had been discontinued after healing and was not reinitiated until after the wound reopened, leaving the resident without an active pressure injury prevention care plan during that period.
Failure to Revise Care Plans to Reflect Monitoring Device Use and Recurrent In-Room Voiding
Penalty
Summary
The deficiency involves the facility’s failure to update and revise comprehensive care plans to reflect current care needs and practices for two residents. One resident with a history of heart failure, paroxysmal atrial fibrillation, cardiomyopathy, stroke, diabetes, and COPD reported during interview that he had a pacemaker and frequently connected himself to a bedside monitoring machine, demonstrating the connection process and stating that staff were aware this was done frequently. Review of his electronic health record and most recent comprehensive care plan showed no interventions or instructions related to the use of this monitoring machine. The unit manager later acknowledged that the care plan had not been revised to include these interventions or instructions. For the second resident, who had a history including CHF, anemia, alcohol dependence with alcohol-induced dementia, MRSA carrier status, and alcohol-induced psychotic disorder with delusions and other behavioral disturbances, surveyors repeatedly observed large puddles of urine on the bedroom floor, including under the bed and in the middle of the floor, accompanied by a strong urine odor. A nurse stated that the puddles were urine and that this resident urinated on the floor all the time, which was the reason he had a private room and could not have a roommate. Review of the resident’s active care plan showed a focus on self-care deficit for toileting with scheduled toileting assistance and a behavioral focus noting episodes of verbal aggression and voiding in the trash can, but it did not include that the resident urinated on the bedroom floor until it was later revised to add that he had daily episodes of urinating on the floor.
Failure to Follow Care Plans, Monitor Changes in Condition, and Implement Toileting and Wound Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and person-centered care plans for three residents. For one resident with a history of stroke, paralysis, aphasia, dysphagia, dementia, seizures, and incontinence, staff did not complete appropriate ongoing assessments and monitoring after a significant change in condition. On the night of the change in condition, the RN documented that the resident was lethargic and unable to respond, with an SBAR note indicating increased stimulation (sternal rub) and stable vital signs at that time. Later documentation showed that IV fluids ordered by the provider could not be started due to difficulty inserting an IV line, and that the resident’s oxygen saturation dropped to 75% on 2 L O2, improving only slightly with increased oxygen. The Unit Manager later confirmed that when he assessed the resident that morning, the heart rate was below 60 and oxygen saturation was 75% on 20 L, and that there were no further neurological assessments or documentation of ongoing monitoring of vital signs or oxygen saturation after the initial change in condition. Another deficiency involved a resident with CHF, alcohol-induced dementia and psychotic disorder, MRSA carrier status, and behavioral disturbances, including voiding in inappropriate places. Surveyors repeatedly observed large puddles of urine on the floor of this resident’s room on multiple days, with a strong urine odor and urine under the bed and in the pathway to the exit. Nursing notes documented multiple episodes of the resident urinating on the floor throughout the month, including descriptions of the floor being urine soaked and housekeeping being called to clean. The resident’s care plan identified self-care deficits in toileting, behavioral issues including voiding in the trash can and on the bedroom floor, and goals to decrease behavioral episodes, with interventions such as offering toileting assistance after waking and meals, ensuring access to a urinal, providing reminders, and assisting with urinal use and emptying. However, behavior monitoring documentation did not reflect these urine-on-floor episodes, and behavior codes for other behaviors were not used. Bladder continence documentation lacked entries on days when urine was observed on the floor, and the 30-day look-back characterized the resident as sometimes continent and sometimes incontinent. Further review of this resident’s bowel and bladder screeners showed that he repeatedly met criteria as a candidate for scheduled toileting (timed voiding), yet the screener indicated that no toileting program was in use. The facility’s bowel and bladder program policy required incontinent residents to be scheduled for elimination tracking and placed on a continence plan, with individualized programs such as scheduled voiding, prompted voiding, or bladder retraining based on cognitive and functional status. Despite this, the MDS documented that no trial of a toileting program had been attempted since urinary incontinence was noted, and the Unit Manager confirmed there had been no evaluation of voiding patterns and no scheduled toileting or bladder program in place. Staff interviews indicated that CNAs documented such episodes simply as incontinence and were not aware of any specific plan to address the resident’s urinating on the floor, while housekeeping reported that the resident urinated on the floor every morning and that she cleaned it at the start of her shift and monitored for further episodes. A third deficiency involved a resident on hospice with a history of acute respiratory failure, muscle weakness, chronic pain syndrome, muscle spasm of the back, major depressive disorder, and Type 2 diabetes with chronic kidney disease, who required assistance with ADLs and had open lesions on the left shin. The physician’s order directed that the left shin be cleansed with normal saline, patted dry, and covered with hydrogel gauze, a non-adherent dressing, and kerlix, secured with tape, every other day and as needed for open lesions. During observation, the resident was seen in bed with a blood-soaked dressing on the left shin and foot, and she reported having open sores due to psoriasis that she picked at. On subsequent observations on two different days, the resident was in bed without any dressing on the left leg. Review of the Treatment Administration Record showed that dressing changes were documented as completed every other day, but there was no documentation on the TAR or in nursing progress notes explaining the absence of dressings on the days observed. The treatment nurse confirmed the wound care order and the documented schedule but could not explain why the resident did not have a dressing on the past two days. Collectively, these findings show that the facility did not ensure that residents received care and treatment according to physician orders, professional standards, and individualized care plans. For the first resident, there was a lack of ongoing neurological and vital sign monitoring after a documented change in condition and difficulty initiating ordered IV therapy. For the second resident, there was a pattern of unaddressed and incompletely documented urinary incontinence behaviors, absence of a toileting program despite policy and assessment findings indicating candidacy, and incomplete behavior and continence documentation. For the third resident, wound care orders for regular and as-needed dressing changes were not consistently implemented or documented in a manner consistent with observed care, as the resident was repeatedly observed without the ordered dressing in place.
Failure to Assist and Supervise Resident Requiring One-Person Ambulation Support
Penalty
Summary
The deficiency involves the facility’s failure to provide supervision and assistance consistent with one resident’s assessed needs and care plan to prevent accidents. The resident had a medical history that included acute respiratory failure, muscle weakness, chronic pain syndrome, muscle spasm of the back, major depressive disorder, and Type 2 diabetes with chronic kidney disease, and was on palliative care. Her care plan documented limited mobility related to her medical condition, with a goal to remain free of complications related to mobility and an intervention specifying that she required one staff member to assist with ambulation using a device for mobility. She had a prior unwitnessed fall that resulted in no injury. On the observed date and time, the resident was seen ambulating rapidly down the hall with a front-wheel walker, calling out to staff. She was wearing a patient gown and jacket, with the gown open in the back, no underwear, and her buttocks exposed. She had no foot coverings, and the dressing on her left lower leg/foot was coming undone and visibly soaked with blood. The only staff present in the area was an RN at the medication cart, who repeatedly told the resident to return to her room but did not stop her task to physically assist or ensure the resident’s safe return, despite the resident’s care plan requirement for one-person assist with ambulation. The unit manager later confirmed that the resident was a one-person assist and that the RN should have assisted her back to her room.
Catheter Drainage Bag Allowed to Touch Floor, Breaching Infection Control
Penalty
Summary
The facility failed to provide appropriate services to prevent urinary tract infections for one resident with an indwelling urinary catheter. A male resident admitted for short-term rehabilitation after a fall with a right femur fracture, and with diagnoses including malignant neoplasm of the prostate and secondary malignant neoplasm of the bone, was observed sitting in a wheelchair in the hallway with his indwelling urinary catheter drainage bag hung under the wheelchair seat and touching the floor. Facility records on the Treatment Administration Record showed staff were required to document each shift that the privacy bag was in place and that the urine collection bag was not touching the floor. During an interview, an RN confirmed that urine collection bags for all residents with indwelling urinary catheters are not supposed to touch the floor. This deficient practice exposed residents with urinary catheters to contaminants that may cause preventable urinary tract infections and had the potential to affect all residents with a urinary catheter.
Failure to Reweigh and Notify Provider After Significant Weight Loss and Poor Intake
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and respond to a resident’s declining nutritional intake and significant weight loss, and to report these changes to the physician. The resident was an elderly female long‑term resident with a history of stroke with right‑sided paralysis, aphasia, oropharyngeal dysphagia, behavioral disturbance, seizures, constipation, and dementia, with severe cognitive impairment (BIMS 99) and total dependence on staff for eating. A nutrition evaluation dated 12/03/25 documented that she was on a modified texture diet with small portions, consuming approximately 75% of meals, receiving 2 Cal HN 237 ml TID, and taking 120–480 ml fluids per meal, with a weight of 171.6 lbs on 10/15/25 and an assessment that oral intake was adequate. However, a subsequent Resident at Risk Review dated 01/17/26 showed a weight of 160.4 lbs on 01/07/26 (mechanical lift), with prior weights of 175.6 lbs on 12/11/25, 171.6 lbs on 10/15/25, and 162.2 lbs on 07/06, indicating a 15.2 lb (8.1%) loss in one month and a significant change. During this period, the resident’s food intake declined to 0–25% for the majority of meals, fluid intake was 151–240 ml per meal, and she was identified as at risk for malnutrition, with oral nutritional supplements noted as her primary source of intake. The registered dietitian documented the significant weight loss, identified the resident as at risk for malnutrition, and recommended a reweigh to confirm the loss and initiation of weekly weights, noting that the weight loss had not been confirmed by reweigh. The RD also confirmed during interview that there was a documented trend of decreased intake and that she had made recommendations for reweigh and weekly weights but was unsure how these recommendations would be communicated to staff for implementation. The unit manager stated that residents are weighed monthly, that policy requires a reweigh when there is significant weight loss, and that the CNAs should perform the reweigh and the dietician and provider should be notified. He confirmed that no reweigh was done and there was no documentation of provider notification. Review of the Weights and Vitals Summary showed no November 2025 weight and no reweigh to verify the January 2026 weight, despite facility policy requiring reweigh and physician notification when there is a 5‑lb or more variance and confirmed significant variance. The hospital discharge summary later documented poor oral intake and inconsistent desire to feed prior to hospitalization, and the resident was ultimately diagnosed with severe hypernatremia and had a PEG tube placed.
Oxygen Tubing Found Disconnected From Concentrator for Resident on O2 Therapy
Penalty
Summary
A deficiency occurred when a resident who was ordered and set up to receive oxygen at 3 L via nasal cannula was found in bed with the oxygen concentrator running, the nasal cannula in place on her face, but the oxygen tubing disconnected from the concentrator and lying on the floor. During the observation, the resident’s oxygen saturation was measured at 85% while she was not in visible distress, and she became upset, stating, "They're trying to kill me!" When questioned, the assigned RN acknowledged that the tubing was not connected and stated that staff might have assisted the resident and dislodged the tubing. The RN also confirmed that staff should check to ensure the tubing is in place before leaving the resident, indicating that this verification had not occurred prior to the surveyor’s observation. This failure to ensure the oxygen tubing was properly connected to the concentrator for a resident receiving oxygen therapy resulted in the resident not receiving the ordered oxygen until the issue was identified during the surveyor’s observation and the tubing was replaced and reapplied.
Failure to Follow Post-Hemodialysis AVF Dressing Orders
Penalty
Summary
The facility failed to provide dialysis access site care as ordered for a resident receiving hemodialysis. The resident, who has an arteriovenous fistula (AVF) in the right arm for hemodialysis, reported that nurses at the facility typically remove the dressing on the day he returns from dialysis or the next morning. The resident’s electronic health record contained a physician order stating that upon return from dialysis, the compression bandage should be kept on no longer than four hours, and if there is known post-dialysis bleeding, the top compression bandage should be removed and the bottom bandage left in place for an additional two to three hours on every day and evening shift after dialysis. The resident’s care plan also directed staff to check and assess the dressing at the access site when back from dialysis and to remove the dressing on the AV fistula as ordered. Record review showed that an RN documented the resident’s return from hemodialysis in the early evening, noting that the AVF dressing was intact, clean, and dry, with no active bleeding and no pain reported at the site. The following morning, the resident was observed sitting in the hallway and confirmed that he still had a dressing on his access site and that he had undergone dialysis the previous day. Upon inspection, a dressing was observed on the upper right arm covering the AVF, indicating that the compression bandage had not been removed within the time frame specified by the physician’s order and care plan. The DON and interim DON confirmed the existence of the time-limited post-hemodialysis AVF dressing order and were unable to explain why the dressing remained in place the next morning.
Incomplete Post-Hospitalization Physician Documentation After Sepsis and PEG Placement
Penalty
Summary
A physician failed to complete a thorough post-hospitalization examination and progress note for a resident following readmission from the hospital. The resident, an elderly female long-term resident with a history of stroke with right-sided paralysis, aphasia, oropharyngeal dysphagia, behavioral disturbance, seizures, urinary and bowel incontinence, and severe cognitive impairment (BIMS 99), had been hospitalized for altered mental status and returned to the facility after treatment. The hospital discharge summary documented severe sepsis due to complicated UTI, severe hypernatremia likely due to poor oral intake and dehydration, combative behavior, severe constipation, an incidental pelvic mass requiring further outpatient MRI evaluation, and placement of a PEG tube for nutrition. On the post-hospitalization visit dated 02/17/26, the attending physician’s progress note documented a general review of systems and physical exam, including stable vital signs, normal HEENT, cardiovascular, respiratory, abdominal, and extremity findings, and an assessment and plan listing CVA with supportive care and constipation managed on the current regimen. However, the note did not indicate that the resident had been recently hospitalized, did not state the reasons for hospitalization, hospital course, or diagnoses, and did not mention that a PEG tube had been surgically inserted and that the resident would now be receiving tube feedings for nutrition. The surveyors determined that the physician’s documentation did not reflect the resident’s current health status on return to the facility, as required.
Insufficient CNA Staffing Leading to Delayed Responses and Incomplete Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to ensure timely, thorough care. Multiple residents and staff reported that the unit was frequently short staffed, with only three to four CNAs assigned to care for a census of 49 residents, despite expectations that five or more CNAs were needed. On one day, the posted daily nursing staff report documented five CNAs for the unit, but only four were observed, and one CNA was reassigned to another unit with a lower census. Staff interviews confirmed that CNAs were often floated off the unit, leaving fewer staff to manage a higher resident load. As a result of this staffing pattern, residents reported delays in response to call lights and changes in the type and quality of hygiene care provided. One resident stated that when staffing was short, CNAs did not have time to provide showers and instead gave bed baths, and this was confirmed by CNA interviews and shower task documentation showing a bed bath provided on a specific date. CNAs reported that providing showers required leaving the wing, which they could not do without leaving insufficient staff to answer call lights, leading them to substitute bed baths, especially for residents who required more time and assistance. Staff also reported that when the unit was short staffed, they rushed care rather than providing quality care. Several residents described specific incidents of delayed incontinent care and prolonged waits for assistance. One resident reported remaining incontinent from approximately 8:00 AM until 12:30 PM after a bowel movement because staff did not respond to assist her. Anonymous residents reported waiting 45 minutes to an hour for staff to respond to call lights, including an instance where a resident slept in urine due to the delay. Residents also reported that staff were overworked, argued about incomplete assignments, and sometimes limited their assistance to their own assigned areas, contributing to incomplete or rushed hygiene care when bed baths were provided.
Medications Left Unattended at Bedside Without Observation
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe administration of medications in accordance with standards of nursing practice by leaving medications at the bedside and not directly observing residents taking them, despite no residents being assessed or authorized to self-administer medications. One resident was observed being handed a cup of medications, including Renvela and Tums for ESRD, by an RN who then left the room without observing ingestion; the resident placed the cup on the bed without taking the medications. Another resident was found with a cup of multiple medications left unattended on the bedside table with water; an LPN later entered, picked up the unattended cup, and then observed the resident take the medications. The facility’s Medication Storage policy requires that during a medication pass, medications must be under the direct observation of the person administering them or locked in a storage area or cart. Additional residents were also found with medications left at the bedside. One cognitively intact male resident receiving hospice care, with a history including dialysis and cancer, had a medication cup with three pills sitting on a cardboard box used as a bedside table; he stated that staff told him to take the medications “now,” but he did not always want to take them immediately. Another female resident with a history of hypertension, obesity, PTSD, urinary incontinence, weakness, and severe recurrent major depressive disorder with psychotic features had medication cups placed on her bedside table by an RN, who then left the room; the resident reported this occurred at other times and identified one cup as Tylenol for later and another cup with several pills for immediate use. The same RN acknowledged leaving medications at the bedside because it was the only way the resident would take them, stated she knew it was wrong, and confirmed awareness of the resident’s history of suicidal ideation. The facility’s self-administration policy requires IDT determination before self-administration and mandates reporting any unauthorized medications found at the bedside, and the DON confirmed that no residents were approved to self-administer medications.
Failure to Document Physician Response to Pharmacist Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the attending physician documented review of the consultant pharmacist’s monthly medication regimen review (MRR) recommendations and actions taken in response for one resident reviewed for unnecessary medications. Review of the resident’s MRR notes from April 2025 through April 2026 showed the pharmacist documented completion of the MRRs and noted on 07/09/25 that a recommendation regarding fluid restriction was being sent. When surveyors requested the July 2025 MRR containing the specific fluid restriction recommendation and the physician’s response, the facility was unable to provide this document for review. The DON in training confirmed the July 2025 MRR for this resident could not be located. Further review of the December 2025 MRR for the same resident revealed the consultant pharmacist recommended a gradual dose reduction trial for Abilify, Trazodone, and Vilazodone. There was no documentation that the attending physician reviewed this MRR or responded to the pharmacist’s recommendations, and the January 2026 MRR showed the pharmacist repeated the same recommendation. The DON in training confirmed there was no documentation that the attending physician addressed the pharmacist’s December 2025 recommendations. This was inconsistent with the facility’s Medication Regimen Review policy, which states that pharmacist-reported irregularities are to be reviewed and a response provided in a timely manner, and that pharmacist recommendations are considered part of the medical record.
Lack of Behavior Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not providing adequate documented behavior monitoring for prescribed psychotropic medications. Physician orders for the resident showed ongoing use of Abilify 5 mg in the evening for depression, trazodone 50 mg at bedtime for depression/anxiety, and vilazodone 10 mg (two tablets) at bedtime for depression. During an interview, the DON in training stated that behavior monitoring is usually documented on the treatment administration record for nursing staff to monitor, but was unable to locate any behavior monitoring documentation related to the resident’s psychotropic medications. The facility’s policy on the use of psychotropic medications requires that such medications be used only when appropriate to treat a resident’s specific diagnoses and documented condition, and that their benefit be demonstrated by monitoring and documentation of the resident’s response, which was not found in this case. This lack of documented behavior monitoring for the resident’s antipsychotic and antidepressant medications resulted in a deficiency related to unnecessary medications, as the facility did not demonstrate through monitoring and documentation that the psychotropic medications were beneficial to the resident as required by its own policy.
Medication Error Involving Administration of Another Resident’s Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a nurse administered another resident’s medications. The affected resident is an adult male with hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, receiving Intermediate Care Facility level of care. A complaint was filed with the Office of Health Care Assurance alleging that the resident had been given another patient’s medications. Review of the resident’s electronic health record showed a progress note documenting that the Unit Manager was notified that a nurse made a medication error and that the resident was given another patient’s medications. The record specified that the resident received multiple medications not prescribed for him, including Tylenol, furosemide, spironolactone, olanzapine, Entresto, Brilinta, metoprolol, aspirin, ticagrelor, venlafaxine, and gabapentin. During an interview, the DON confirmed that RNs are trained and instructed to identify residents using two identifiers (name and date of birth) at all times. Review of the facility’s “Medication Administration” policy, revised 03/01/26, showed that staff are instructed to identify the resident by photo in the MAR, review the MAR to identify the medication to be administered, and compare the medication source to verify resident name, medication name, form, dose, route, and time. Despite these policies and training, the nurse did not follow the required resident identification and medication verification steps, resulting in the administration of another resident’s medications.
Unsecured Medication and Treatment Carts with Broken Lock and Unlocked Cart in Hallway
Penalty
Summary
Surveyors identified a deficiency related to improper storage and security of medications and medical supplies. On the Lewalani Unit, observation of the treatment cart showed that the cart lock was broken, allowing anyone to open the cart drawers and access all medications and medical supplies. During an interview, the treatment nurse acknowledged that the cart was not secured. In a separate observation during the initial facility tour, a medication cart was seen in the hallway unlocked and unsecured while an RN walked out of a resident’s bedroom; the RN then returned to the cart but left it unlocked, and later stated that the cart should be locked and secured when not in use or when leaving to administer medications to residents. In a subsequent interview, the DON confirmed that medication carts should always be locked and secured when not in use. Review of the facility’s “Medication Storage” policy, revised 03/2026, stated that all drugs and biologicals will be stored in locked compartments. The observed unsecured treatment and medication carts, in contrast to facility policy and staff acknowledgments, constituted the basis for the cited deficiency.
Failure to Honor Resident’s Documented Food Preferences and Restrictions
Penalty
Summary
The facility failed to honor a resident’s documented food preferences and diet specifications when serving meals. During a dining observation, the resident reported she was not supposed to have gravy or chicken skin, yet her lunch tray contained chicken with the skin on and gravy covering the chicken. Review of the resident’s meal card on the tray showed an order for a No Added Salt (NAS) diet with explicit instructions for no sauce, gravy, or chicken skin. The resident further reported that her dinner plate the previous evening had a lot of gravy, and she did not report the concern to staff because she did not want to complain and was worried her meal would arrive later if she did. Review of the facility’s daily dinner menu for that evening showed that crispy pork cutlet with gravy was served, indicating that the resident’s stated and documented preferences and restrictions were not followed.
Improper Sanitizer Concentration and Inadequate Staff Training Documentation in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service sanitation practices when sanitation solutions in kitchen sanitation buckets were not maintained at the correct concentration level. During an observation, a dietary aide tested the sanitizer in a red bucket using a Hydrion QT-40 test strip and initially stated the strip should remain in the solution for 15 seconds, while the container’s directions specified a 10-second dip without shaking before comparing colors. When the aide retested the first bucket following the product instructions, the sanitizer concentration was still out of range and did not reach the required 150–400 PPM, and testing of a second red bucket also showed the solution to be out of range. In a subsequent interview, the dietary manager was only able to provide training materials and rosters from 2024 related to preparation and use of sanitation solutions and buckets, and could not produce any training materials or staff rosters for 2025–2026 prior to the survey, stating that some records had been moved and might be located elsewhere. The deficient practice places the residents at risk for spread of foodborne illness.
Failure to Implement Infection Control Practices, Contact Precautions, and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including proper use of contact precautions, Enhanced Barrier Precautions (EBP), and hand hygiene. A resident with C. difficile infection was on contact precautions with posted signage requiring gowns and gloves upon entry and soap-and-water hand hygiene on exit. Despite this, a registered nurse exited the room after care and used only alcohol-based hand rub (ABHR) instead of washing with soap and water, and an activities assistant entered the room without gown and gloves, left a paper schedule at the bedside, and used ABHR on exit, stating she had been told PPE was not needed if not touching the resident. A visitor was also observed in the same room without a gown, even though nursing staff stated that everyone entering the room should wear a gown and gloves and wash hands with soap and water due to the resident’s C. difficile status. Facility policy for management of C. difficile required all staff to wear gloves and a gown upon entry and to perform hand hygiene with soap and water. Additional observations showed staff not performing required hand hygiene between resident contacts and care tasks. During lunch service, a CNA and the infection preventionist were passing meal trays; the CNA was observed entering multiple rooms, assisting residents to sit up in bed, adjusting pillows, and placing trays and straws without performing hand hygiene between tray delivery and resident care. During a medication pass, an RN administered crushed medications in pudding to a resident, then removed soiled gloves and immediately donned clean gloves to administer eye drops without performing hand hygiene between glove changes. When questioned, the RN acknowledged that she was supposed to wash hands with soap and water or use hand sanitizer after removing dirty gloves. The facility also failed to consistently implement Enhanced Barrier Precautions and to ensure hand hygiene after contact with bodily fluids and contaminated equipment. Two CNAs provided shower care to a resident under EBP, handling disposable items and linens and using a shower chair, without wearing gowns despite posted EBP signage and facility policy requiring gowns and gloves for high-contact care activities such as bathing and hygiene assistance. In another room with EBP signage, one resident was observed taking his roommate’s trash bin, which had two urinals attached, one containing urine. He removed the trash bag, discarded it in the soiled utility room, later picked up the urine-filled urinal from the floor, emptied it into the toilet, and returned it to the trash bin. An LPN present did not encourage or ensure that the resident performed hand hygiene after handling urine and contaminated equipment.
Infection Control and PPE Deficiencies Identified
Penalty
Summary
Multiple deficiencies in infection prevention and control were observed during the survey. Staff failed to perform proper hand hygiene between tasks, such as when a CNA assisted a resident with lunch, then handled used meal trays and other residents, and returned to feeding without sanitizing hands. The Director of Nursing confirmed that hand hygiene is required between tasks, and facility policy specifies hand hygiene before and after direct resident contact and when assisting with meals. Additional observations included staff not performing hand hygiene after doffing PPE and before accessing clean supplies, despite policy requirements for hand hygiene before and after entering transmission-based precaution areas and after handling food. Further deficiencies were noted in the management of medical equipment and infection control practices. A resident's catheter bag was found partially uncovered and in direct contact with the floor, rather than being properly hung from the bed frame. In another instance, respiratory care equipment, including a suction catheter, was not dated or stored correctly, and the tubing was not changed according to the facility's stated schedule. The Infection Preventionist confirmed these practices were not in line with facility policy, which requires suction catheters to be changed every 24 hours. The facility also failed to follow its own protocols for Covid-19 testing and use of personal protective equipment (PPE). Residents who were exposed to Covid-19 positive roommates were not tested within the required timeframes outlined in the facility's policy. Additionally, staff were observed assisting residents on contact precautions without wearing the required PPE, such as gowns, and some staff were unsure of the correct PPE to use. These lapses were confirmed by staff interviews and review of facility policies.
Failure to Provide Required Transfer/Discharge Notifications and Incomplete Notification Forms
Penalty
Summary
The facility failed to provide required written notifications of transfer or discharge to residents, their representatives, and the Office of the State Long-Term Care Ombudsman for two of three sampled residents. Specifically, for one resident who was transferred and discharged to the hospital on two occasions, there was no documentation of written notification to the resident, their representative, or the Ombudsman. The Director of Social Activities confirmed that written notifications were not provided and was unaware that such notifications were required. Additionally, the transfer/discharge notification form used by the facility did not include the Ombudsman's address as required by policy. For another resident with three hospitalizations, there was no discharge or transfer notification found for any of the hospitalizations. Although discharge notices were sent to the Ombudsman for two of the hospitalizations, there was no proof that notification was sent to the resident's representative. The notification form used was also missing the Ombudsman's address and information about appeal rights. The Director of Social Activities stated that notifications were not sent for all types of transfers, including those for observation stays, contrary to regulatory requirements.
Failure to Provide Consistent Range of Motion Services
Penalty
Summary
The facility failed to provide consistent and adequate range of motion (ROM) treatment and services to two residents with significant mobility limitations. One resident, admitted with hemiplegia affecting the left side and contractures in the left hand and both elbows, was observed multiple times without the prescribed right arm splint and left hand roll. Interviews with restorative staff confirmed that the resident was not receiving the required ROM exercises at the prescribed frequency, with documentation showing that both splint application and ROM exercises were only completed on a few days in April and May, rather than the six times per week as ordered in the care plan. Another resident, admitted with hemiplegia and hemiparesis following a stroke, was also not consistently provided with passive ROM (PROM) exercises as outlined in their care plan. Observations over several days showed the resident in bed with foot pads on, but no evidence of ROM activity during multiple shifts. Staff interviews revealed that PROM was not being provided at the required frequency due to staffing shortages, and the treatment administration record confirmed that PROM was only completed on a few days in April and May, rather than the three times per week specified in the care plan. The Director of Nursing acknowledged that both residents did not have consistent ROM completed, and staff interviews emphasized the importance of these interventions in maintaining mobility and preventing further contractures. The facility's own restorative program policy states the intent to help residents achieve and maintain their highest functional level, but the observed and documented care did not meet these standards for the two residents involved.
Failure to Provide Adequate Supervision and Safe Environment for Residents
Penalty
Summary
The facility failed to minimize the risk of preventable accidents for two residents by not providing adequate supervision and not ensuring a safe environment. One resident with a history of wandering, hemiplegia, dementia, and poor safety awareness was repeatedly observed walking unaccompanied in hallways and between units without staff supervision. Despite being identified as high risk for falls and serious injuries, and care plan interventions calling for close supervision or frequent visual checks, the resident was seen wandering alone on multiple occasions. Staff interviews confirmed that the resident required more supervision to ensure safety, and that her wandering behavior was sometimes upsetting to other residents. Another resident, identified as a current smoker with mobility limitations due to right hip osteoarthritis, was observed using a designated smoking area that did not meet facility policy requirements for safety. The area was unpaved, uneven, and surrounded by flammable plants and brush. There was no fire extinguisher present, and a plastic trash can with a thin liner was located near the smoking area. The resident and staff were observed disposing of cigarette butts in the plastic trash can instead of the required fire-proof receptacle. The DON confirmed that this was not in accordance with facility policy, which mandates a fire extinguisher and proper disposal of smoking materials in a fire-proof receptacle. The facility's policies on accident hazards and supervision require individualized interventions and environmental modifications to reduce risks, as well as specific safety measures for residents who wander and for designated smoking areas. The observed practices did not align with these policies, resulting in increased risk of avoidable accidents and injuries for the residents involved.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents requiring such services. One resident, who was non-verbal, bedbound, and had significant contractures to both hands, was observed without prescribed hand splints or hand rolls on multiple occasions. During passive range of motion (PROM) exercises, the resident exhibited clear signs of pain, such as deep facial grimacing and tightly closed eyes, yet was not pre-medicated for pain prior to the intervention. The staff member performing PROM acknowledged the resident's pain but continued the exercise until stopped by the surveyor. It was also found that the resident did not have any pain medication ordered prior to the incident, and staff were not consistently following care plan interventions for pain assessment and management. Another resident, whose preferred language was Vietnamese, was not assessed for pain in a manner she could understand. Despite her repeated attempts to communicate pain using picture cards and the Vietnamese word for pain, staff relied solely on the absence of facial grimacing to assess her pain level. The Wong-Baker Faces Pain Rating Scale, which should have been available for non-English speaking residents, was not present at the bedside, and staff were unfamiliar with the available picture cards. Pain assessments were consistently documented as zero, and pain medication was administered without proper assessment or communication with the resident in her preferred language. Both cases demonstrate a failure to accurately assess, monitor, and manage pain according to the residents' needs and care plans. The facility did not ensure that staff were adequately trained or equipped to recognize and respond to non-verbal or culturally specific expressions of pain, resulting in inadequate pain control and failure to maintain the residents' highest practicable level of well-being.
Failure to Ensure Residents Understand Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that three residents and their representatives fully understood the Binding Arbitration Agreement during the admission process. Interviews revealed that one family representative did not remember signing the agreement and was unaware of its contents, citing the overwhelming number of admission forms. Another resident stated she signed all admission papers but did not recall any discussion about the arbitration agreement and was unfamiliar with its details, indicating she would not have signed if she had known it waived her right to a traditional court trial. A third resident also did not remember signing the agreement or understanding its purpose, expressing indifference due to not having issues with the facility at the time. A staff interview with the Business Office Manager confirmed that the facility follows its policy regarding arbitration agreements during admissions. Review of the facility's policy indicated that residents and their representatives should be informed of the nature and implications of the agreement, including their right to refuse without affecting admission or continued care. The policy also requires that the agreement be explained in a manner and language the resident or representative understands, and that acknowledgment of understanding is obtained. Despite these policy requirements, the sampled residents and representative did not demonstrate understanding of the agreement, leading to the deficiency.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
Staff members failed to maintain resident dignity during mealtime assistance by not following facility protocols that require CNAs to sit at eye level with residents while feeding them. Multiple observations showed CNAs standing over residents while assisting with meals, mixing food, and intermittently leaving the residents unattended. In one instance, a CNA stood while feeding a resident, left to retrieve a meal tray, returned to stir the food, and then left again to assist another resident, before finally returning to continue feeding. These actions were observed to occur without the CNA sitting down to maintain eye contact or provide focused attention. Additionally, staff were observed conversing with each other about work matters instead of focusing on the residents they were assisting. Interviews with CNAs confirmed awareness that they should be sitting beside residents to ensure comfort and effective communication. An LPN interviewed was unsure of the proper procedure but acknowledged that residents should not feel intimidated. The DON confirmed that the facility's practice is for staff to sit at eye level with residents during meal assistance to promote dignity and communication. These observations and interviews demonstrate a failure to provide care in a manner that maintains resident dignity for all residents requiring meal assistance.
Failure to Include Resident Representatives in Care Planning
Penalty
Summary
The facility failed to ensure the inclusion of residents' representatives in the care planning process for two residents with severe cognitive impairment. One resident, who was observed to have dementia and a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, was unable to make significant decisions regarding his care. The resident's representative confirmed that while the resident could make minor day-to-day choices, he was not capable of making major decisions. Despite this, the representative was not invited to participate in the resident's care plan meeting and was not given the opportunity to provide input on the resident's goals, choices, and preferences. Documentation confirmed that only the resident was listed as attending the care plan meeting, and staff acknowledged that there was no record of the representative being notified or invited. For the second resident, also with severe cognitive impairment as indicated by a low BIMS score, the family representative reported that care planning meetings were sporadic and that formal meetings were not consistently conducted. Review of the electronic health record and interviews with staff confirmed that the last care planning meeting for this resident was held several months prior, and the required quarterly meeting was missed. The process for scheduling and documenting care planning meetings was described, but it was confirmed that the necessary meeting for this resident did not occur as required. These findings demonstrate that the facility did not facilitate the participation of residents' representatives in the care planning process for residents who were unable to make their own significant care decisions. As a result, the representatives were not able to support or provide input on the residents' care plans, which is a requirement for residents with severe cognitive impairment.
Medications Left at Bedside Without Clinical Assessment for Self-Administration
Penalty
Summary
A resident with moderately impaired cognitive skills, as documented in her Minimum Data Set (MDS) assessment, was found to have at least six different medications left at her bedside for self-administration. The resident did not respond verbally to questions about the medications. Nursing staff confirmed that the medications were her morning doses and acknowledged that medications should not be left at the bedside. The nurse responsible for leaving the medications stated he was working an extra shift and gave out medications early, confirming he should not have left them unattended. Further review of the resident's electronic health record revealed no assessment had been completed to determine if she was clinically appropriate to self-administer her medications. The Director of Nursing confirmed the absence of such an assessment and stated that, given the resident's cognitive status, she would not be appropriate for self-administration. The facility's policy on self-administration of medications was requested but not provided before the survey exit.
Failure to Accommodate Resident Shower Preferences and Ensure Mechanical Lift Availability
Penalty
Summary
The facility failed to accommodate the shower preferences and transfer needs of a resident who was fully dependent on staff for mobility and required a mechanical lift for transfers. The resident, who could not bend her knees, was unable to use the available shower chairs, including a reclining model that still required knee flexion. As a result, she only received bed baths instead of showers, despite her and her family’s expressed preference for weekly showers. Staff interviews confirmed that there were no shower gurneys available on the floor or in the facility to meet the needs of residents who could not sit up or safely use a shower chair. Additionally, the facility did not ensure the continuous availability of a mechanical lift for the nine residents on the floor who required it. There was only one mechanical lift on the floor, which was sometimes taken to other floors, leaving residents without access to necessary transfer equipment. Staff confirmed that the single lift was insufficient to meet the needs of all residents requiring mechanical assistance, and that the lack of equipment directly impacted the ability to provide appropriate care.
Failure to Honor Resident's Shower Preference
Penalty
Summary
A deficiency was identified when the facility failed to honor and support a resident's preference for showering. The resident, a female admitted for long-term care, was fully dependent on staff for toileting and required maximal assistance for showering and personal hygiene. Her Minimum Data Set (MDS) assessment indicated that it was somewhat important for her to choose between a tub bath, shower, bed bath, or sponge bath. Despite this, the facility did not identify or document her specific bathing preference. The resident's family representative reported that the resident wished to have a shower at least once a week but was only provided with bed baths, a concern that had been communicated to staff. Interviews with facility staff revealed a lack of awareness regarding the resident's preferences. A Certified Nurse Aide (CNA) confirmed that the resident was scheduled for baths twice a week but only received bed baths, and was unaware of any specific shower preference. The Director of Nursing (DON) acknowledged during a review that the facility had not identified or documented the resident's choice regarding bathing method. The facility also failed to secure the necessary equipment to accommodate the resident's shower preference, resulting in her needs not being met and hindering her from attaining her highest practicable well-being.
Failure to Provide Quarterly Personal Fund Statements to Residents
Penalty
Summary
The facility failed to provide quarterly personal fund statements directly to two residents who maintained trust accounts with the facility. Both residents were determined to be their own responsible persons and were cognitively intact or nearly intact, as indicated by their BIMS scores. Despite facility policy requiring quarterly statements to be provided to residents and/or their responsible parties, the statements were only sent to addresses on file, which were not the facility addresses where the residents resided. Interviews with the residents confirmed that they did not receive their statements unless specifically requested, and in one case, the statements were sent to a family member instead of the resident. The Business Office Manager (BOM) confirmed that there was no documentation or tracking system in place to verify that statements were delivered to the residents. The BOM acknowledged that, despite a previous citation for the same issue, there was no evidence that the residents had received their statements as required. As a result, the residents were not made aware of their current account balances and were not given the opportunity to periodically reconcile their accounts, as stipulated by facility policy.
Failure to Secure Electronic Health Records at Documentation Station
Penalty
Summary
Surveyors observed that an ICARE documentation station, used by CNAs and RNAs to record resident care tasks and interactions, was left open and accessible in a high-traffic hallway near the entrance to a wing. The open station displayed a resident's personal and clinical information, including code status, allergies, diet, and required treatment monitoring. Staff interviews confirmed that the station should have been closed and exited out after use to maintain privacy and comply with HIPAA requirements. The Director of Nursing and other staff acknowledged that leaving the station open was not in accordance with facility policy or privacy regulations. Review of the facility's policy confirmed the expectation for privacy and confidentiality of resident records.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents. One resident was observed multiple times in her room with fall mats on both sides of her bed that were dirty with black marks. Despite repeated observations over several days, the condition of the mats did not change, and a housekeeper was unable to confirm when the mats were last cleaned, acknowledging their dirty state. Another resident was consistently observed sitting in a hallway area directly beneath a ceiling tile with a large black spot. Nursing staff were unaware of the dirty ceiling tile and had not reported it to maintenance. The issue was only addressed after it was pointed out by a surveyor. The maintenance supervisor later indicated the damage might have been from an old leak, but could not determine the source, and the tile was found to be dry.
Failure to Accurately Assess Resident Status Due to Incomplete Observation and Language Barriers
Penalty
Summary
The facility failed to conduct accurate assessments for two residents, resulting in their needs not being properly identified or met. One resident, a female with severe cognitive impairment, left-sided weakness from a stroke, and a history of falls, was observed wandering unsupervised on and off the unit over several days. Despite these observations and the daily use of a wander/elopement alarm, her Minimum Data Set (MDS) quarterly review did not code her as exhibiting wandering behaviors. The MDS coordinator stated that wandering may not have been observed during the assessment period, but the surveyor noted multiple documented instances of wandering during that time. Another resident, a female admitted for long-term care with a preferred language of Vietnamese, was marked as "rarely/never understood" on her MDS Annual Assessment, and the Brief Interview for Mental Status (BIMS) was not conducted. The Social Services Director attempted the assessment using a phone interpreter in Cantonese, which was not the resident's language, resulting in poor communication. The resident's family confirmed she only speaks Vietnamese and demonstrated during an interview that she could communicate effectively when interpreted correctly. The facility's policy requires accurate documentation of residents' medical, functional, and psychological status, which was not followed in these cases.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, resulting in unmet medical, physical, mental, and psychosocial needs. For one resident with vascular dementia, hemiplegia, and incontinence, the care plan addressed incontinence and skin integrity, but observations revealed improper peri-care technique by a CNA, including wiping from back to front, which was acknowledged as incorrect by both the CNA and the DON. This improper technique was observed during a brief change, and new areas of skin breakdown were identified, despite the care plan's goal to prevent such issues. Interviews with staff confirmed inconsistent knowledge and application of proper peri-care procedures, and the resident's care plan did not fully address her needs or prevent the decline in skin condition. Another resident, whose preferred language is Vietnamese, did not have a care plan that included a person-centered communication plan or interpreter services, despite this being identified as a need. This omission meant that the resident's communication preferences and needs were not accurately reflected or addressed in her care plan, potentially impacting her ability to communicate effectively with healthcare staff. A third resident with a history of trauma and mental health diagnoses did not have a trauma-informed care plan that included identified triggers and specific interventions, even though the facility's policy required such plans. The resident's psychosocial evaluation documented anxiety related to large crowds, but this was not incorporated into the care plan. The lack of individualized, comprehensive care planning for these residents resulted in deficiencies that placed them at risk for a decline in their quality of life and prevented them from attaining their highest practicable well-being.
Failure to Revise Care Plan and Provide Intervention for Dialysis Access Site
Penalty
Summary
The facility failed to revise the care plan for one resident receiving dialysis and did not provide an intervention for the resident's dialysis access site after returning from dialysis with a pressure dressing in place. The resident, who has a history of end stage renal disease, hypertensive heart and chronic kidney disease, diabetes, dementia, and dependence on renal dialysis, was observed with a dressing on his upper left arm after returning from dialysis. The resident reported that the dressing was applied at the dialysis center and that sometimes nurses at the facility remove it and apply Band-Aids if there is still bleeding. Review of the resident's care plan showed it included monitoring for complications from hemodialysis, avoiding blood draws or blood pressure measurements on the arm with the arteriovenous fistula, encouraging attendance at dialysis appointments, and monitoring for signs of infection or renal insufficiency. However, the care plan did not include specific interventions for the care of the dialysis access site or removal of the pressure dressing after dialysis. Interviews with nursing staff revealed inconsistent practices regarding who is responsible for removing the pressure dressing and when it should be removed. One nurse stated that the night shift is responsible, while another indicated that the dressing is usually removed within two hours of the resident's return from dialysis, but confirmed it was not removed as expected. The Director of Nursing confirmed that there was no established protocol for the removal of the pressure dressing prior to contacting the dialysis center for guidance. The lack of a clear intervention in the care plan and inconsistent staff practices resulted in the resident retaining the pressure dressing for an extended period after returning from dialysis, without appropriate assessment or intervention documented in the care plan.
Failure to Provide Communication Supports for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide appropriate care and treatment to support the communication abilities of two residents whose primary languages were not English. Upon admission, both residents were identified as needing interpreter services and alternative communication methods, but the facility did not implement effective person-centered communication plans. For one resident who spoke only Vietnamese, the care plan inaccurately listed her primary language as both Cantonese and Vietnamese, and there was no evidence that interpreter services were used. The resident's family representative confirmed that interpreter services were never offered or used, and staff did not request her assistance to interpret. Observations revealed that communication aids, such as picture cards with Vietnamese words, were not accessible at the bedside, and there were no pain scale cards available to assess the resident's pain level. For the second resident, whose preferred language was Mandarin, the facility's staff were unaware of the available professional translator service and could not locate the communication board intended for the resident's use. The communication board was found on the roommate's side of the room, out of reach. Interviews with staff revealed that they primarily relied on gestures to communicate and were not aware of the translator service or the communication tools that should have been available. The facility's policy required the use of communication methods in a language familiar to the resident, but this was not followed in practice. These deficiencies were identified through observation, interviews, and record review, and demonstrated that the facility did not ensure residents with limited English proficiency had access to necessary communication supports. As a result, the residents were at increased risk of not having their needs met and were hindered from attaining their highest practicable well-being.
Failure to Timely Remove Dialysis Pressure Dressing and Assess Access Site
Penalty
Summary
A resident who required dialysis returned to the facility with a pressure dressing still in place on their left forearm fistula after a morning dialysis session. The resident reported that the nurse typically removes the dressing after returning from dialysis. However, observations revealed that the pressure dressing remained on the resident's arm into the following morning. The resident stated that the dressing had been removed the previous night but was reapplied by the night shift nurse due to continued bleeding. The pressure dressing was not removed until late the next morning, after it was brought to the attention of the registered nurse, who had not been informed by the night shift about the status of the dressing and had not yet assessed the access site due to the resident's early appointment. The Director of Nursing confirmed that the pressure dressing should be removed a few hours after dialysis and the access site checked for bleeding every shift, unless there are specific physician orders to leave the dressing on. The dialysis provider advised that if bleeding is present, the dressing may remain for a couple of hours but should be assessed every two to three hours and removed once bleeding stops. The failure to remove the pressure dressing in a timely manner and to properly communicate and assess the access site led to the deficiency.
Failure to Timely Assess and Identify Resident Trauma History
Penalty
Summary
The facility failed to adequately assess and identify past trauma for a resident admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. Upon review, it was found that no trauma screening was conducted at the time of admission, despite the facility's policy requiring such screening. The psychosocial assessment, which included only one question about trauma, was not completed until more than two months after admission. Additionally, the Social Services Life Event Checklist, intended to assist in creating a trauma-informed care plan, was not completed in a timely manner and all responses were marked as not applicable. Interviews with the Social Services Director and staff revealed that there was no formal trauma screen form in use, and the required trauma-informed care training had only been completed by the Social Services Director, with no evidence of completion by other social services staff. The resident, who is cognitively intact, disclosed a significant traumatic event from his past during an interview, which had not been previously identified or addressed in his care planning.
Failure to Provide Person-Centered Behavioral Health Services and Supervision
Penalty
Summary
The facility failed to provide necessary behavioral health care and services that were person-centered and reflected the resident's goals for care, specifically for one resident with a history of hemiplegia, hemiparesis, and dementia. This resident was observed multiple times wandering unsupervised in hallways and other units, taking food from other residents' trays and rooms, and displaying aggressive behaviors such as hitting and making threatening gestures. Other residents and staff reported ongoing distress and complaints about these behaviors, noting that staff responses were limited to redirection and explanations rather than increased supervision or intervention. Interviews with residents, staff, and social services personnel revealed that the underlying causes of the resident's behaviors were not clearly understood or documented in the care plan. The care plan included general interventions such as providing supervision and offering assistance, but observations showed that these measures were inconsistently implemented. Staff and social services acknowledged the need for more supervision and indicated that referrals to psychiatric services were delayed or not current, with the last psychiatric evaluation dated two years prior. Facility policy required the provision of medically related social services and timely referrals for mental and psychosocial counseling, but documentation and interviews indicated that these processes were not effectively followed. The lack of timely psychiatric evaluation, insufficient supervision, and inadequate person-centered behavioral interventions contributed to ongoing behavioral issues that affected both the resident and others on the unit.
Early Medication Administration and Incomplete Narcotic Count Documentation
Penalty
Summary
A deficiency was identified when a registered nurse administered morning medications to a resident more than two hours before the scheduled time, without ensuring the required safety parameters were met. The medications, which included blood pressure medications with specific hold parameters, were left at the resident's bedside before they were due. The nurse did not obtain or verify the resident's vital signs prior to administration, instead relying on data from a certified nurse aide whose shift had not yet started, making it impossible for the data to have been available at the time of administration. The nurse later confirmed that medications for multiple residents were given early to accommodate his work schedule. Further review revealed that the medication administration record was inaccurately documented, as the nurse recorded the medications as being given on time, despite administering them early. The facility's policy requires medications to be administered within one hour of the scheduled time and for vital signs to be obtained and recorded when applicable. The nurse's actions were inconsistent with these policies, and the nurse supervisor confirmed that this practice should not occur. Additionally, a separate deficiency was noted regarding the facility's narcotic count procedures. During a medication cart audit, it was found that the narcotic count sheet was not fully completed, with missing signatures and verification fields for both the day and afternoon shifts. The director of nursing confirmed that licensed staff are required to sign the narcotic count sheet after reconciliation, as outlined in the facility's policy. The incomplete documentation failed to ensure proper accountability and reconciliation of controlled substances.
Failure to Act on Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that recommendations made by the consultant licensed pharmacist (CLP) during the monthly medication regimen review (MRR) were acted upon for a resident. Specifically, for a male resident with diagnoses including spinal stenosis, atrial fibrillation, and anxiety disorder, one MRR recommendation regarding a gradual dose reduction (GDR) or clinical contraindication (CC) for Trazadone was not followed up in a timely manner. Although a provider eventually declined the recommendation, documentation of timely review and follow-up was lacking. Additionally, another MRR recommendation noted the discontinuation of Trazadone and the initiation of Lexapro, with a plan to discuss the change at the next psychotropic meeting. However, there was no documentation available to confirm that this discussion took place, as the requested psychotropic meeting minutes were not provided. The DON confirmed that unit managers are responsible for reviewing MRRs within one week, but the absence of documentation indicates this process was not consistently followed.
Medication Storage, Labeling, and Administration Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the storage, labeling, and administration of medications. One resident was found sitting in a wheelchair with a medication cup containing pills and a loose pill on the table, while the assigned RN was distracted and not directly supervising the resident. The RN did not immediately notice the loose pill until prompted by the surveyor. The facility's policy and the DON confirmed that nurses are required to observe residents taking their medications, which was not followed in this instance. Additional observations included improper storage and labeling of medications in the medication cart. Discontinued and unlabelled medications were found stored with active medications, including controlled substances not being properly counted or removed after discontinuation or resident discharge. The DON confirmed that these medications should have been removed and disposed of according to facility policy, but this was not done. These actions and inactions resulted in medications not being stored, labeled, or administered in accordance with professional standards.
Failure to Accommodate Resident Food and Drink Preferences
Penalty
Summary
A resident with diagnoses including diabetes, end stage renal disease, hemodialysis, heart failure, and high cholesterol was not provided with food and drink that accommodated his stated preferences. Despite repeated requests over several weeks for specific items such as a turkey sandwich with cheese for lunch, tea instead of milk, and dry cereal for breakfast, these preferences were not honored by the facility. As a result, the resident refused to eat the food provided by the facility and relied on outside food brought in by family members, leading to feelings of malnourishment and weakness. Interviews with staff revealed ongoing miscommunication between nursing and kitchen staff regarding the resident's diet waiver, which allowed him to eat preferred foods. The Food Services Director acknowledged the miscommunication and confirmed that the resident's preferences had not been consistently accommodated. Facility policy requires that food and drink be provided in accordance with resident preferences, but this was not followed in the resident's case.
Failure to Properly Label and Discard Resident Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During an observation in the kitchenette, one food container was found labeled with a resident's name but without a date, and another container was labeled with a resident's name, room number, and a date that was seven days old. When questioned, the Restorative Nurse Aide (RNA) stated that the process is to label food with the resident's name, date, and room number, and to discard it after three days. The RNA acknowledged the improper labeling and agreed that the food should be discarded. These findings were confirmed with an LPN and an RN present at the nurses station. Further interview with a kitchen staff member clarified that the kitchen is responsible for maintaining the nourishment refrigerators and food from the kitchen, while nursing staff are responsible for labeling and discarding food brought in from outside or saved after meals. The facility's policy requires outside food to be labeled with the resident's name, room number, and date, and stored in a designated refrigerator. However, the facility did not provide a policy specifying how long food items should be stored before being discarded.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for one resident by not documenting medication administration in accordance with accepted professional standards. Specifically, a registered nurse administered at least six different medications to the resident more than two hours before the scheduled 09:00 AM time, but did not document the administration until approximately 08:50 AM, which was only ten minutes before the medications were due. The nurse confirmed that the medications were given early and that the documentation did not reflect the actual time of administration, as the electronic health record system did not allow for documentation more than one hour before the scheduled time. Observations at the resident's bedside confirmed the presence of the medications on the table, and interviews with both the nurse supervisor and the Director of Nursing verified that facility policy requires medications to be administered no more than one hour before or after the scheduled time and that documentation should occur immediately after administration. The inaccurate documentation made it appear as if the medications were given on time, when in fact they were not, and this was acknowledged by both the nurse and the Director of Nursing as not aligning with facility and nursing standards.
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Multiple failures to maintain resident dignity and timely care were identified, including a resident left waiting over an hour for assistance to urinate despite documented mobility deficits, and two residents with indwelling urinary catheters whose drainage bags were left uncovered and visible from the hallway contrary to facility policy. During a Resident Council meeting, residents reported that certain CNAs did not consistently provide basic morning hygiene, ignored or delayed responses to call lights, and sometimes turned off call lights after learning a request involved incontinence care without returning, resulting in residents remaining soiled for extended periods and care being left for the next shift.
Staff failed to keep call systems within reach for three LTC residents who were incontinent and dependent on staff for ADLs, including residents with arthritis, bipolar disorder, chronic pain, stroke with one-sided impairment, and hemiplegia/hemiparesis. Surveyors observed call lights and call pads placed toward the head of the bed, behind the bed on a light fixture, or hanging on the wall above the bed, all out of the residents’ reach during multiple observations. These practices did not follow the facility’s policy requiring call lights to be within reach and accessible while residents are in bed.
Multiple rooms on one unit were found with environmental deficiencies, including broken and unsecured electrical outlets, damaged and stained walls and ceilings, improvised extensions on light cords using a plastic bag and a washcloth, dripping and constantly running sink faucets with discolored grout, and a strong urine odor in one room. A review of work orders and an interview with the Facilities Director showed that only two work orders had been submitted for this unit, both generated after surveyor observations, indicating that unit staff had not routinely initiated maintenance requests for these conditions.
The facility failed to adequately inform and assist multiple residents with Advance Health Care Directives (AHCDs). One resident requested an AHCD form but received no documented follow-up or assistance, and this issue was not addressed in later interdisciplinary team meetings. Another resident had a Five Wishes AHCD document on file that lacked required witness signatures, despite clear instructions that witnessing was necessary for validity. A third resident initially declined an AHCD, but the facility did not periodically revisit the discussion, and the resident later reported that no one had discussed AHCDs with him and expressed a desire to complete one.
Surveyors observed that the lab specimen refrigerator had brown stains on the door and bottom shelves and multiple small dead bugs on the door shelf, demonstrating that staff failed to maintain a clean environment in an area used for specimen storage. The Infection Prevention Nurse acknowledged the refrigerator was dirty.
Surveyors found that the facility failed to develop and maintain comprehensive care plans for two residents, one receiving an anticoagulant and psychotropic meds for vascular dementia with agitation, and another with a history of sacral pressure ulcers and a high Braden risk score. The first resident’s care plan did not address anticoagulant use or dementia-related care despite active orders and facility policy requiring individualized dementia care planning. The second resident’s care plan lacked any pressure ulcer prevention or management interventions, even though prior sacral ulcers had healed with documented preventive measures in place and the ulcer later reopened; staff confirmed the resident’s high risk and the absence of an active pressure injury prevention care plan during that time.
The facility failed to revise care plans for two residents to reflect current care needs and behaviors. One resident with multiple cardiac and pulmonary conditions, including HF, AFib, and COPD, reported frequent self-connection to a bedside pacemaker monitoring device known to staff, yet the comprehensive care plan contained no interventions or instructions regarding this monitoring. Another resident with CHF, alcohol-induced dementia, MRSA carrier status, and psychotic disorder was repeatedly observed with large urine puddles on the bedroom floor, and an RN stated that this resident urinated on the floor regularly and therefore had a private room, but the active care plan only addressed scheduled toileting and episodes of voiding in a trash can, without documenting the ongoing behavior of urinating on the floor.
A deficiency was identified in which three residents did not receive care according to professional standards and their care plans. One resident with severe cognitive impairment and multiple comorbidities experienced an acute change in condition, but staff did not perform or document ongoing neuro checks or vital sign and O2 monitoring after the initial assessment and were unable to initiate ordered IV fluids. Another resident with CHF, alcohol-induced dementia, and behavioral issues was repeatedly found with large puddles of urine on the floor, while behavior and continence documentation did not capture these episodes, and no scheduled toileting or bladder program was implemented despite assessments and facility policy indicating the need. A third resident on hospice with open shin lesions had physician orders for every-other-day and PRN wound dressings, yet was observed on multiple occasions without a dressing in place, even though the TAR reflected that treatments had been completed and nursing staff could not explain the discrepancy.
A resident with limited mobility, multiple chronic conditions, and a history of a recent unwitnessed fall was care planned as a one-person assist for ambulation using a device. On observation, the resident was moving rapidly down the hall with a front-wheel walker, calling out to staff, wearing an open gown with no underwear, no foot coverings, and with a left lower leg/foot dressing coming undone and visibly soaked with blood. The only staff present, an RN at the med cart, repeatedly instructed the resident to return to her room but did not stop to provide hands-on assistance or ensure safe return, despite the documented requirement for one-person assist. The unit manager confirmed that the resident required one-person assistance and that the RN should have helped her back to her room.
A resident receiving short-term rehab with an indwelling urinary catheter was observed in a wheelchair with the catheter drainage bag hung under the seat and touching the floor, despite facility documentation requirements that staff verify each shift that privacy bags are in place and drainage bags are not on the floor. An RN confirmed that catheter bags are not supposed to touch the floor, indicating a failure to follow established catheter care and infection control practices.
Failure to Maintain Resident Dignity, Privacy, and Timely Response to Care Needs
Penalty
Summary
The deficiency involves multiple failures to honor residents’ rights to dignity, respect, and timely assistance with care needs. One resident reported that after an activities session she informed staff she needed to urinate but was told to wait; staff did not return for over an hour, and it was the next shift that ultimately assisted her. She stated she did not feel treated with respect or dignity. Her electronic health record showed diagnoses including diabetes, chronic kidney disease, chronic pain, borderline personality, and schizoaffective disorder, and her care plan documented mobility and self-performance deficits due to significant muscle weakness and debility. Surveyors also observed two residents with indwelling urinary catheters whose drainage bags were positioned facing the bedroom door and visible from the hallway without privacy bags in place, despite multiple observations over several hours. The RN and DON both confirmed that catheter drainage bags should always be covered with privacy bags, and facility policy on catheter care and promoting/maintaining resident dignity required catheter bags to be covered at all times while in use and that staff maintain resident dignity and respect resident rights. During a Resident Council meeting, residents reported that certain CNAs did not consistently respond to care needs, did not provide basic morning hygiene such as wiping faces and hands, and sometimes turned off call lights after asking if the need involved urine or bowel movement without returning to provide incontinence care, leaving care for the next shift. Two residents reported remaining in their bowel movements for about one and a half hours after lunch when staff did not return after call lights were activated, and one resident stated staff respond more quickly when the bathroom call light is used.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves staff failing to ensure that resident call systems were within reach for multiple residents who were dependent on staff for activities of daily living. One resident with arthritis, bipolar disorder, chronic pain, and total bowel and bladder incontinence was observed in bed with her call light cord positioned toward the head of the bed and out of her reach; when asked, she confirmed she could not reach it and requested that it be moved closer. Another resident with a history of stroke and one-sided impairment, who was incontinent and dependent on staff for ADLs, was observed lying in bed without access to the gray call pad, which was hanging on a light fixture behind the bed; he stated he was able to use the call pad, but it was not placed where he could reach it until a CNA later repositioned it. A third resident with hemiplegia and hemiparesis affecting the left non-dominant side, impaired left upper extremity, and functional limitation in upper extremity range of motion was repeatedly observed lying comfortably in bed while the call light was left hanging on the wall above the bed and out of reach. This resident was able to communicate verbally and move the right upper extremity, but the call light remained out of reach during multiple observations on different days and times. Review of the facility’s policy titled “Call Light: Accessibility and Response” showed that staff were required to ensure the call light was within reach of the resident and accessible while the resident was in bed, which was not followed in these instances.
Failure to Maintain Homelike and Well-Maintained Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the Pensacola 1 unit, as evidenced by multiple environmental deficiencies observed in six resident rooms. In one room, a wall clock was broken with a large piece missing and several white patches were visible on the wall. Another room had multiple large brown marks of unknown substance on the wall that were immediately visible upon entry. A separate room had a loud, constant buzzing noise whenever the bathroom light was turned on. Additional observations included several visible water marks on a ceiling, a broken electrical plug plate, and a heavily damaged wall behind a bed. Other rooms showed further environmental issues, including a wall light over a bed that had a cord extended with a plastic bag so the resident could reach it, and an electrical outlet at the head-of-bed wall that was not secure and was visibly coming out of the wall. One room had a dripping sink faucet and very discolored grout around the sink, while another had a strong smell of urine. Yet another room had a sink faucet that was constantly running, and one bed area had a washcloth attached to the light cord to extend its reach and six large screws or hooks in the wall. Interview with the Facilities Director revealed that unit staff were expected to complete work orders for needed repairs, but only two open work orders existed for this unit, both related to issues reported during the survey, indicating that routine work orders had not been submitted by unit staff for the observed problems.
Failure to Inform and Assist Residents With Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to properly inform and assist residents with formulating Advance Health Care Directives (AHCDs) and to ensure that existing AHCD documents were validly executed. For one resident (R17), the EHR showed that AHCD information was discussed and the resident requested a blank AHCD form on 04/14/25. However, there was no subsequent documentation that the resident completed an AHCD or that the facility provided follow-up assistance after that date. The Social Services Assistant (SSA) confirmed there was no follow-up documentation, and the most recent interdisciplinary team meeting record for this resident contained no reference to AHCD follow-up. For another resident (R170), the facility obtained a completed Five Wishes document intended to serve as an AHCD, but the document lacked required witness signatures, despite instructions on the form stating it must be signed and witnessed as directed to be legal and valid. The SSA confirmed the absence of witness signatures. For a third resident (R153), the EHR showed that AHCD information was last discussed on 12/10/24, at which time the resident declined to formulate an AHCD. There was no evidence that the facility revisited the discussion or reoffered assistance after that date. In a subsequent interview, this resident reported that the facility had not discussed an AHCD with him and stated he would like to complete one.
Unclean Lab Specimen Refrigerator Compromises Environmental Cleanliness
Penalty
Summary
Surveyors identified a deficiency related to the resident’s right to a safe, clean, comfortable, and homelike environment when the lab specimen refrigerator was found to be unclean. During an observation of the refrigerator, brown stains were noted on the door shelf and bottom shelf, and multiple small dead bugs were present on the door shelf. In a subsequent interview, the Infection Prevention Nurse acknowledged that the lab specimen refrigerator was dirty. These conditions demonstrated that the facility failed to maintain a clean environment in the area where lab specimens are stored.
Failure to Develop Comprehensive Care Plans for Anticoagulant Use, Dementia, and Pressure Ulcer Prevention
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive, individualized care plans addressing all identified needs for two residents. For one resident with vascular dementia and agitation, record review showed an active order for Eliquis 2.5 mg twice daily with instructions to monitor for adverse reactions, but the resident’s care plan did not address the use of this anticoagulant medication. During interview, the MDS RN confirmed that the anticoagulant should have been included in the care plan. The same resident had diagnoses including vascular dementia with agitation and was prescribed psychotropic medications, yet the care plan did not include dementia-related care. The MDS RN verified that dementia care should have been incorporated, despite the facility’s own dementia policy requiring individualized care plans that consider symptoms, disease progression, and co-existing conditions. The second resident had a history of sacral/buttocks pressure ulcers that had previously healed, with APRN documentation that preventive interventions such as scheduled repositioning, pressure-relieving devices, incontinence care, and protective dressings remained in place. A subsequent wound clinic note documented that the prior sacral ulcer site had broken down again, with fat layer exposed, and attributed contributing factors including moisture-associated skin damage and trauma from a shower chair. The resident reported that the wound may have reopened due to prolonged time in a wheelchair without repositioning assistance and stated that staff did not consistently assist with repositioning every two hours as recommended. Review of the care plan revealed no documented interventions for pressure ulcer prevention or management, despite a Braden Scale score of 11 indicating high risk. Nursing staff confirmed the resident was at high risk for pressure ulcer development and that the care plan did not include pressure ulcer prevention interventions, and the MDS RN reported that the pressure injury care plan had been discontinued after healing and was not reinitiated until after the wound reopened, leaving the resident without an active pressure injury prevention care plan during that period.
Failure to Revise Care Plans to Reflect Monitoring Device Use and Recurrent In-Room Voiding
Penalty
Summary
The deficiency involves the facility’s failure to update and revise comprehensive care plans to reflect current care needs and practices for two residents. One resident with a history of heart failure, paroxysmal atrial fibrillation, cardiomyopathy, stroke, diabetes, and COPD reported during interview that he had a pacemaker and frequently connected himself to a bedside monitoring machine, demonstrating the connection process and stating that staff were aware this was done frequently. Review of his electronic health record and most recent comprehensive care plan showed no interventions or instructions related to the use of this monitoring machine. The unit manager later acknowledged that the care plan had not been revised to include these interventions or instructions. For the second resident, who had a history including CHF, anemia, alcohol dependence with alcohol-induced dementia, MRSA carrier status, and alcohol-induced psychotic disorder with delusions and other behavioral disturbances, surveyors repeatedly observed large puddles of urine on the bedroom floor, including under the bed and in the middle of the floor, accompanied by a strong urine odor. A nurse stated that the puddles were urine and that this resident urinated on the floor all the time, which was the reason he had a private room and could not have a roommate. Review of the resident’s active care plan showed a focus on self-care deficit for toileting with scheduled toileting assistance and a behavioral focus noting episodes of verbal aggression and voiding in the trash can, but it did not include that the resident urinated on the bedroom floor until it was later revised to add that he had daily episodes of urinating on the floor.
Failure to Follow Care Plans, Monitor Changes in Condition, and Implement Toileting and Wound Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and person-centered care plans for three residents. For one resident with a history of stroke, paralysis, aphasia, dysphagia, dementia, seizures, and incontinence, staff did not complete appropriate ongoing assessments and monitoring after a significant change in condition. On the night of the change in condition, the RN documented that the resident was lethargic and unable to respond, with an SBAR note indicating increased stimulation (sternal rub) and stable vital signs at that time. Later documentation showed that IV fluids ordered by the provider could not be started due to difficulty inserting an IV line, and that the resident’s oxygen saturation dropped to 75% on 2 L O2, improving only slightly with increased oxygen. The Unit Manager later confirmed that when he assessed the resident that morning, the heart rate was below 60 and oxygen saturation was 75% on 20 L, and that there were no further neurological assessments or documentation of ongoing monitoring of vital signs or oxygen saturation after the initial change in condition. Another deficiency involved a resident with CHF, alcohol-induced dementia and psychotic disorder, MRSA carrier status, and behavioral disturbances, including voiding in inappropriate places. Surveyors repeatedly observed large puddles of urine on the floor of this resident’s room on multiple days, with a strong urine odor and urine under the bed and in the pathway to the exit. Nursing notes documented multiple episodes of the resident urinating on the floor throughout the month, including descriptions of the floor being urine soaked and housekeeping being called to clean. The resident’s care plan identified self-care deficits in toileting, behavioral issues including voiding in the trash can and on the bedroom floor, and goals to decrease behavioral episodes, with interventions such as offering toileting assistance after waking and meals, ensuring access to a urinal, providing reminders, and assisting with urinal use and emptying. However, behavior monitoring documentation did not reflect these urine-on-floor episodes, and behavior codes for other behaviors were not used. Bladder continence documentation lacked entries on days when urine was observed on the floor, and the 30-day look-back characterized the resident as sometimes continent and sometimes incontinent. Further review of this resident’s bowel and bladder screeners showed that he repeatedly met criteria as a candidate for scheduled toileting (timed voiding), yet the screener indicated that no toileting program was in use. The facility’s bowel and bladder program policy required incontinent residents to be scheduled for elimination tracking and placed on a continence plan, with individualized programs such as scheduled voiding, prompted voiding, or bladder retraining based on cognitive and functional status. Despite this, the MDS documented that no trial of a toileting program had been attempted since urinary incontinence was noted, and the Unit Manager confirmed there had been no evaluation of voiding patterns and no scheduled toileting or bladder program in place. Staff interviews indicated that CNAs documented such episodes simply as incontinence and were not aware of any specific plan to address the resident’s urinating on the floor, while housekeeping reported that the resident urinated on the floor every morning and that she cleaned it at the start of her shift and monitored for further episodes. A third deficiency involved a resident on hospice with a history of acute respiratory failure, muscle weakness, chronic pain syndrome, muscle spasm of the back, major depressive disorder, and Type 2 diabetes with chronic kidney disease, who required assistance with ADLs and had open lesions on the left shin. The physician’s order directed that the left shin be cleansed with normal saline, patted dry, and covered with hydrogel gauze, a non-adherent dressing, and kerlix, secured with tape, every other day and as needed for open lesions. During observation, the resident was seen in bed with a blood-soaked dressing on the left shin and foot, and she reported having open sores due to psoriasis that she picked at. On subsequent observations on two different days, the resident was in bed without any dressing on the left leg. Review of the Treatment Administration Record showed that dressing changes were documented as completed every other day, but there was no documentation on the TAR or in nursing progress notes explaining the absence of dressings on the days observed. The treatment nurse confirmed the wound care order and the documented schedule but could not explain why the resident did not have a dressing on the past two days. Collectively, these findings show that the facility did not ensure that residents received care and treatment according to physician orders, professional standards, and individualized care plans. For the first resident, there was a lack of ongoing neurological and vital sign monitoring after a documented change in condition and difficulty initiating ordered IV therapy. For the second resident, there was a pattern of unaddressed and incompletely documented urinary incontinence behaviors, absence of a toileting program despite policy and assessment findings indicating candidacy, and incomplete behavior and continence documentation. For the third resident, wound care orders for regular and as-needed dressing changes were not consistently implemented or documented in a manner consistent with observed care, as the resident was repeatedly observed without the ordered dressing in place.
Failure to Assist and Supervise Resident Requiring One-Person Ambulation Support
Penalty
Summary
The deficiency involves the facility’s failure to provide supervision and assistance consistent with one resident’s assessed needs and care plan to prevent accidents. The resident had a medical history that included acute respiratory failure, muscle weakness, chronic pain syndrome, muscle spasm of the back, major depressive disorder, and Type 2 diabetes with chronic kidney disease, and was on palliative care. Her care plan documented limited mobility related to her medical condition, with a goal to remain free of complications related to mobility and an intervention specifying that she required one staff member to assist with ambulation using a device for mobility. She had a prior unwitnessed fall that resulted in no injury. On the observed date and time, the resident was seen ambulating rapidly down the hall with a front-wheel walker, calling out to staff. She was wearing a patient gown and jacket, with the gown open in the back, no underwear, and her buttocks exposed. She had no foot coverings, and the dressing on her left lower leg/foot was coming undone and visibly soaked with blood. The only staff present in the area was an RN at the medication cart, who repeatedly told the resident to return to her room but did not stop her task to physically assist or ensure the resident’s safe return, despite the resident’s care plan requirement for one-person assist with ambulation. The unit manager later confirmed that the resident was a one-person assist and that the RN should have assisted her back to her room.
Catheter Drainage Bag Allowed to Touch Floor, Breaching Infection Control
Penalty
Summary
The facility failed to provide appropriate services to prevent urinary tract infections for one resident with an indwelling urinary catheter. A male resident admitted for short-term rehabilitation after a fall with a right femur fracture, and with diagnoses including malignant neoplasm of the prostate and secondary malignant neoplasm of the bone, was observed sitting in a wheelchair in the hallway with his indwelling urinary catheter drainage bag hung under the wheelchair seat and touching the floor. Facility records on the Treatment Administration Record showed staff were required to document each shift that the privacy bag was in place and that the urine collection bag was not touching the floor. During an interview, an RN confirmed that urine collection bags for all residents with indwelling urinary catheters are not supposed to touch the floor. This deficient practice exposed residents with urinary catheters to contaminants that may cause preventable urinary tract infections and had the potential to affect all residents with a urinary catheter.
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