Failure to Ensure Call Lights Were Accessible and Functional for Residents
Summary
The facility failed to ensure that call lights were within reach or functioning for three residents, as required by their care plans and facility policy. One resident with chronic obstructive pulmonary disease, acute kidney failure, and mild cognitive impairment was observed lying in bed with the call light placed on the far back corner of the nightstand, covered by a curtain and not within reach or sight. Another resident with spinal stenosis, heart failure, and a history of falls was observed sitting in a recliner with the call light placed on the footboard of the bed, hanging down between the mattress and footboard, also out of reach and sight. In both cases, the care plans specified that call lights should be kept within reach due to the residents' fall risks and physical limitations. An LPN confirmed that the call lights were not accessible to these residents at the time of observation. A third resident, who had diabetes with polyneuropathy, a recent amputation, and required assistance with multiple activities of daily living, was found to have a non-functioning call light. The resident reported that the call light had not worked for about a week and was given a bell to ring for help instead. Observations confirmed that the call light did not activate the indicator outside the door when pressed. The Director of Plant Operations later verified that the call light cord connected to the new system was not provided to the resident and was found lying on the floor out of reach. The facility's policy required staff to ensure call lights were plugged in and within reach, which was not followed in these instances.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple cardiac and visual diagnoses, who required assistance with mobility and used an air mattress, repeatedly requested bed handrails due to a fear of falling out of bed. Staff reportedly told the resident that handrails were not allowed, and the facility had a practice of not using handrails with pressure-reducing air mattresses without performing individualized assessments. Despite the resident’s documented care needs and known fear of transfers, there was no assessment, care plan intervention, or evaluation in the medical record addressing the request for handrails, even though facility policy and manufacturer guidance called for individualized assessment of bedrail use.
A resident with a documented care‑planned preference to use an electronic monitoring device in a private room was not accommodated when facility staff repeatedly interfered with and ultimately removed the camera. The care plan directed staff not to obstruct or damage recording devices, yet the resident’s daughter reported two prior cameras had been damaged, and the most recent camera—used for many months—was taken away by the Administrator, despite a door posting indicating electronic recording. The Administrator and nursing leadership cited the camera’s ability to pan and the daughter’s use of two‑way audio as reasons for removal, even though the written monitoring policy only required fixed‑position cameras and did not prohibit audio. The daughter demonstrated that the camera could be locked in a fixed position and provided multiple emails documenting Wi‑Fi failures that caused the camera to reset and rotate, as well as requests for maintenance intervention, but the facility produced no records of addressing these issues, no concern‑log entries supporting claims of ongoing noncompliance, and no explanation for a missing SD card from the camera when it was returned, resulting in failure to support the resident’s right to maintain the monitoring device.
The facility failed to maintain an adequate supply of washcloths and towels for residents’ daily hygiene, leading staff to use disposable incontinence wipes or paper towels instead of proper linens. A cognitively intact resident with muscle weakness and pressure ulcers, who required assistance with ADLs and was care-planned to use washcloths with step-by-step guidance, was observed being fully washed with disposable wipes because no washcloths or towels were available. Checks of linen closets on both floors found no washcloths or towels, and CNAs reported this shortage occurred several days a week, leaving residents unable to wash until laundry was completed. The Director of Housekeeping and the Administrator acknowledged the ongoing problem, citing laundry practices, lack of backup stock, and staff discarding or hoarding linens, while multiple residents and an RN confirmed repeated mornings without washcloths or towels and unresolved concerns raised in resident council meetings.
A resident with severe cognitive impairment and mental health diagnoses required supervision for multiple ADLs but was observed lying in bed without access to a call light, as the cord was on the floor and too short to reach from the wall to the bed. A CNA confirmed the resident could not reach the call light because of the inadequate cord length, resulting in a failure to reasonably accommodate the resident’s needs for call system access.
A Spanish‑speaking resident with multiple serious medical conditions and intact cognition had her preferred language documented as Spanish, yet her care plan lacked any communication interventions. Staff reported that the resident spoke very little English and routinely called her daughter to translate for admission paperwork, daily needs, and standardized assessments such as the BIMS and PHQ‑9. Although an interpreter service and app were reportedly available per leadership and policy on culturally competent care, several staff either did not know how to access these services or relied instead on family members, hand gestures, or bilingual staff. This resulted in the facility failing to ensure staff could effectively communicate with the resident in her preferred language.
The facility failed to follow its own policy requiring prompt notification of the attending physician or provider when residents left against medical advice (AMA). In two separate cases, a resident with multiple chronic conditions and cognitive impairment who later tested cognitively intact signed out AMA, and another resident with cerebrovascular disease, COPD, major depressive disorder, and essential HTN was taken out AMA by a Guardian. In both instances, documentation showed the residents left AMA, but there was no evidence that the Medical Director or provider was notified, and leadership later confirmed that no such notifications occurred.
Failure to Assess and Accommodate Resident Request for Bed Handrails
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s expressed need and preference for bed handrails by not conducting an individualized assessment or evaluation. Resident #43, admitted with diagnoses including total retinal detachment of the left eye, asthma, chronic ischemic heart disease, and acute on chronic systolic heart failure, had an air mattress ordered for skin prevention and required assistance with bed mobility, transfers, toileting, dressing, and hygiene. The resident’s care plan identified a two-person assist for transfers and noted behavioral issues related to refusals of treatment and a preference for keeping the bed in the highest position despite education on fall risks. However, the medical record contained no documented assessment, care plan intervention, or evaluation related to the resident’s request for handrails to address a fear of falling. During observation and interview, the resident reported a longstanding fear of falling out of bed and stated he had been requesting handrails for approximately one year, but staff told him that “state would not allow handrails” and no assessment had been completed. At the time of observation, the resident’s bed had an air mattress and no handrails. The Administrator and DON stated that residents with pressure-reducing air mattresses automatically did not have handrails due to entrapment risk and confirmed the facility did not perform individual risk assessments for handrails when an air mattress was in use, despite staff being aware of the resident’s fear of transfers since admission. The Administrator later acknowledged that the medical record lacked documentation of any assessment or interventions related to the handrail request and that both facility policy and the air mattress manufacturer’s guidance required individualized assessment of bedrail use based on the resident’s physical and mental status.
Failure to Honor Resident’s Care‑Planned Preference for Electronic Monitoring Device
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s longstanding, care‑planned preference to use an electronic monitoring device in her private room. The resident’s care plan, initiated in June 2024, documented her preference for electronic monitoring and directed staff not to obstruct, tamper with, or destroy recording devices. Despite this, the resident’s daughter reported that two prior cameras had been damaged by staff, and the most recent camera, in place since June 2025, was removed by the Administrator in March 2026 against the resident’s wishes. At the time of survey, the resident’s room displayed a notice of electronic recording, but no camera was present. Care conference documentation from December 2025 showed that the Administrator discussed alternate placement with the resident and POA, stating the facility could not meet the resident’s needs and that the POA was non‑compliant with the camera policy, but the notes did not specify how the policy was violated or what steps were taken to honor the resident’s right to use the device. The Administrator later informed the daughter that the camera had been removed for noncompliance with policy. During interviews, the Administrator and nursing leadership stated the camera was removed because it could pan the room and be remotely controlled, and because the daughter had spoken or yelled at staff through the camera, even though the written electronic monitoring policy only required fixed‑position cameras and did not prohibit two‑way audio. The resident’s daughter demonstrated that the camera could be set to a fixed position via an app and explained that frequent Wi‑Fi outages in the resident’s room caused the camera to reset and rotate automatically, prompting her repeated, documented email requests for maintenance to address Wi‑Fi failures. Emails over many months indicated the camera was always set to a fixed position and not on motion tracking, and raised concerns about Wi‑Fi disruptions, but the facility did not provide documentation of responses or corrective measures. The facility also provided no documentation of any new or immediate safety risk justifying abrupt removal of the camera, no concern‑log entries reflecting the Administrator’s claim of ongoing camera‑related issues, and no explanation or investigation regarding the missing SD memory card from the camera when it was returned to the daughter. These actions and omissions resulted in the facility not supporting continuation of the resident’s electronic monitoring device in accordance with her rights, preferences, and care plan.
Ongoing Lack of Washcloths and Towels Limits Residents’ Ability to Perform Daily Hygiene
Penalty
Summary
The facility failed to ensure a sufficient supply of washcloths and towels was available for residents’ morning care and as needed, resulting in residents being washed with disposable wipes or unable to wash at all. One cognitively intact resident, admitted with diagnoses including myocardial infarction, muscle weakness, and stage three and stage two pressure ulcers to the buttocks, required assistance with ADLs and incontinence care. This resident’s care plan included instructions for staff to provide simple, step-by-step guidance for self-care tasks such as using a washcloth to wash the face. During observed morning care, the CNA assisting this resident used disposable wipes intended for incontinence care to wash the resident’s face and entire body because there were no clean washcloths or towels available, despite the resident expressing a preference to have at least a washcloth for the face. Further observations on both floors of the skilled nursing facility showed that the linen closets on all halls contained no washcloths or towels for resident use. CNAs confirmed that these closets were the only storage areas for washcloths and towels on their respective floors and reported that this lack of linens occurred on multiple days, with residents sometimes having to wait until laundry was completed before they could be washed for the day. The Director of Housekeeping explained that laundry staff worked an eight-hour shift starting between 7:00 and 8:00 a.m., and that they washed tablecloths and napkins first upon arrival. She confirmed that there were no clean towels or washcloths available that morning for any residents, that she ordered linens monthly, and that staff frequently threw linens away. She also confirmed there was no backup supply in stock and that staff reported the lack of towels and washcloths two to three times per week. Interviews with nursing staff and residents corroborated that the shortage of washcloths and towels was an ongoing issue. A registered nurse stated that on some days there were no washcloths or towels in the mornings, and that residents could only use wipes for their bottoms. Multiple residents reported that there were times they could not wash up in the mornings due to the lack of washcloths and towels, with one resident stating they had to use paper towels instead. The Administrator acknowledged awareness of the ongoing problem and stated that it was especially an issue when agency staff worked, as they either discarded linens or hoarded them in certain residents’ rooms. Resident council minutes documented unresolved concerns about insufficient towels and toilet paper in residents’ bathrooms and for showers, and noted that the council had previously met with the Administrator about the towel issue.
Failure to Keep Call Light Within Reach Due to Inadequate Cord Length
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was kept within reach, as required to reasonably accommodate the resident’s needs and preferences. Medical record review showed the resident was admitted with diagnoses including disorganized schizophrenia, depression, and anxiety, and an MDS assessment documented severe cognitive impairment. The MDS further indicated the resident required set-up assistance with oral hygiene and supervision for toileting, bathing, dressing, and personal hygiene, while being independent with eating, bed mobility, and transfers. During an observation, the resident was seen lying in bed with the call light cord on the floor and out of reach, and the cord was noted to be too short to extend from the wall to the resident’s bed. In an interview, a CNA confirmed that the resident did not have access to the call light because the cord was not long enough to reach the bed. This combination of the resident’s severe cognitive impairment, need for supervision with ADLs, and the physical placement and length of the call light cord resulted in the resident not having access to the call system while in bed, constituting the cited deficiency.
Failure to Provide Effective Interpreter Services for Spanish‑Speaking Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate the communication needs and preferences of a Spanish‑speaking resident whose preferred language was documented as Spanish and whose ethnicity was documented as Mexican. The resident was cognitively intact, with a BIMS score of 14, and had multiple serious medical diagnoses including disseminated malignant neoplasm, secondary malignant neoplasms, neoplasm‑related pain, depression, anemia in neoplastic disease, muscle weakness, and unsteadiness on feet. Despite this, the resident’s care plan did not include any focus on her primary language or interventions to address communication needs. During observation, the resident was seen calling her daughter because she did not speak English. Interviews with staff and the resident’s daughter showed that the resident relied heavily on her daughter to translate for her throughout the day and night. The daughter reported that the facility initially mentioned a translator but never provided one. Multiple staff members, including an LPN, the Admissions Coordinator, and the Unit Manager, stated that the resident spoke very little English and typically called her daughter when she needed something. The Admissions Coordinator had the resident sign admission paperwork while her daughter translated over the phone, and Social Services completed the BIMS and PHQ‑9 assessments through the daughter’s in‑person translation rather than using an interpreter service. Staff described using hand gestures, slower speech, or other staff who spoke Spanish, instead of consistently using a formal interpreter. Several staff members, including Social Services and LPNs, either did not know how to access the interpreter service, were unsure if one existed, or defaulted to using family members when available. Social Service staff acknowledged there was no specific reason for not calling an interpreter service and stated they did not know the interpreter service number or where it was located. In contrast, the Regional Social Worker and Unit Manager stated that the facility had an interpreter service account and that staff should be using it, and the DON stated there was an interpreter service and an app available, while also noting that staff should be careful using family as interpreters. Review of the facility’s Culturally Competent Care policy showed that the purpose was to ensure care that respects and responds to residents’ cultural and linguistic preferences, but staff interviews and observations demonstrated that this policy was not effectively implemented for this resident, resulting in a failure to ensure staff could communicate with her in her preferred language.
Failure to Notify Physician of Residents’ AMA Discharges
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy requiring prompt notification of the attending physician or provider when a resident leaves against medical advice (AMA). For one resident admitted with chronic viral hepatitis C, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression, and venous insufficiency, the record showed moderately impaired cognition on the most recent MDS, with independence in eating, partial assistance with toileting, substantial assistance with bathing, and setup for personal hygiene. On the day of discharge, the resident’s BIMS score was 13, indicating cognitively intact status, and the resident signed an Unauthorized Discharge Release of Responsibility form to leave AMA after the facility documented discussion of the risks and attempts to have the resident remain. However, the Medical Director/provider was not notified of this AMA discharge, and the Medical Director later confirmed he had never been informed. A second resident, admitted with cerebrovascular disease, COPD, major depressive disorder, and essential HTN, had an MDS indicating independence with eating, dependence on staff for toileting and bathing, and partial assistance with personal hygiene. This resident was discharged AMA by the resident’s Guardian, as documented in a progress note. Review of the medical record revealed no documentation that the Medical Director/provider was notified when the resident left AMA, and the Regional Clinical Director confirmed that the provider was not notified at that time. The facility’s written policy titled “Discharging a Resident Without a Physician’s Approval” states that when a resident or representative requests discharge earlier than outlined in the care plan and without physician approval (AMA), the attending physician or provider is to be promptly notified. The failure to notify the physician/provider for both AMA discharges constituted non-compliance and was cited under Complaint Number 2699059.
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