Mirage Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, California.
- Location
- 44445 15th St W, Lancaster, California 93534
- CMS Provider Number
- 056039
- Inspections on file
- 130
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 70
Citation history
Health deficiencies cited at Mirage Post Acute during CMS and state inspections, most recent first.
A resident with cerebral ischemia, muscle weakness, a history of falls, and a daily aspirin order for CVA prevention developed unexplained discoloration to the chin and forehead, documented via SBAR after staff could not identify a fall or clear cause. Nursing leadership, including the ADON and DON, acknowledged the resident was on anticoagulant therapy, had a history of agitation and a tendency to hurt herself, yet there were no care plans addressing anticoagulant/aspirin use or behavioral issues such as agitation, restlessness, or self-injury, contrary to the facility’s comprehensive person-centered care plan policy.
The facility failed to maintain accurate, objective medical records for two residents. For one resident with a history of CVA and falls, a practitioner’s progress note incorrectly documented that the resident had recently fallen and sustained a left shoulder dislocation, chin bruising, and a forehead bump, despite leadership confirming no fall had occurred. For another resident with dementia and severe protein-calorie malnutrition, an SBAR form for a fall inaccurately recorded that a physician recommended an X-ray of the right arm and elbow, when the LPN later admitted this was her own assumption and no X-ray order existed in the physician orders or progress notes. Additionally, the resident’s fall care plan labeled the event as a witnessed fall, while the SBAR described the resident as being found on the floor, creating conflicting documentation about whether the fall was witnessed, contrary to the facility’s policy requiring complete and accurate charting.
Failure to Provide Advance Directive Information and Documentation: The SSD did not provide written information about the right to accept or refuse treatment and to formulate an AD for multiple residents. One resident with stroke-related deficits had no AD in PCC, two residents had incomplete AD/POLST documentation and no evidence they were given AD information, and another resident refused to sign an AD form because family involvement was requested, but the request was not documented and no follow-up with the family representative was noted.
Failure to Document and Assess Physical Restraint Use: Surveyors found that a bed placed against the wall for three residents and a pillow tucked under the sheets for one resident were used as restraints without the required MD order, informed consent, restraint assessment, or care plan. Staff, including RNs, LVNs, the DSD, and the DON, confirmed the positioning and stated these practices limited movement and were considered restraints, while the residents had diagnoses including weakness, impaired mobility, cognitive impairment, vision impairment, dementia, obesity, and other conditions affecting function.
Failure to Care Plan Lorazepam Use and Hot/Cold Gel Pack Self-Administration: A resident with dementia, anxiety, and DM had a PRN lorazepam order, but the ADON stated there was no care plan for the medication or monitoring of adverse effects, black box warning issues, dependence, or withdrawal reactions. Another resident with polyneuropathy, chronic pain, HTN, and COPD was being monitored for self-administration of a hot/cold gel pack, but an LVN stated there was no physician order or comprehensive person-centered care plan for that self-administration.
A resident had Visine and A&D ointment left at the bedside despite no order and no desire to self-administer meds. Another resident’s bed was found in a high position even though the care plan called for the lowest setting. A third resident had a call light cord with frayed, exposed wires, and two fall-risk residents had bedside tables placed on top of floor mats intended to cushion falls.
A resident who was incontinent had an unlabeled urinal at the bedside, another resident with an indwelling catheter had no stat lock or leg strap in place, and a third resident was observed with a 20 Fr Foley despite an order for 16 Fr. Staff and the DON/DSD stated the urinal should have been labeled, the catheter should have been secured, and the ordered catheter size was not followed.
A facility failed to provide respiratory care consistent with orders and infection control practices for four residents. One resident had an unlabeled bedside suction canister, another had NC tubing touching the floor, a third had an incomplete oxygen order and care plan without titration parameters or pulse oximetry frequency, and a fourth was receiving oxygen at a higher flow rate than ordered. Staff and the DON acknowledged the issues during observation and interview.
Bed rails were used for three residents without the required documentation and authorization. One resident with hemiplegia and fluctuating decision-making capacity had bilateral half side rails in use, but RN and DON stated there was no current physician order or care plan for side rail use. Two other residents, including one with Alzheimer's disease and seizures and another with hemiplegia and intact cognition, had orders and assessments for 1/4 rails, but were observed or documented with 1/2 rails instead; the DSD and DON stated the specific 1/2 rail use lacked the proper order, informed consent, assessment, and care plan.
Failure to Rotate Insulin Injection Sites: The DON and DSD identified that insulin injections were repeatedly given in the same subcutaneous sites for multiple residents despite orders and manufacturer guidance to rotate sites. Records showed repeated use of the same abdominal and arm locations for insulin administration, and the facility acknowledged this was not in accordance with the prescriber’s orders, standards of practice, or insulin labeling.
A cook did not follow the fortified diet instructions during lunch trayline service and used a household tsp instead of the required 1 oz measure of melted margarine on potatoes and vegetables. The DS and DON stated the correct scoop or ladle should have been used to ensure residents on fortified diets received the intended calorie density and nutrients.
Unsafe food storage and labeling practices were observed in the kitchen. Wet meal trays and food storage bins were stacked before air drying, spoiled onions and a dented can were mixed with other stored food, and several opened food items, including milk products and bread products, were not labeled with an open date. The DS and DM acknowledged the labeling, storage, and drying issues during the survey.
Antibiotic stewardship monitoring and order deficiencies were identified for three residents. One resident receiving Augmentin had missing q-shift adverse-effect documentation, another resident had Hiprex ordered for UTI prevention without an end date and Cefuroxime ordered with an improper indication, and a third resident receiving Daptomycin had no documented q-shift monitoring for adverse effects. The facility’s records and staff interviews showed that antibiotic orders and monitoring were not consistently completed as required by policy.
Frayed and exposed wires were observed on bed remote controls in the rooms of three residents, including residents with impaired cognition, mobility dependence, and diagnoses such as paraplegia, muscle weakness, and depression. Staff stated the exposed wiring should not have been present because of the risk of electrocution, and one bed remote was also not working when used for care. In a separate room, a resident’s call light did not activate the light outside the door or ring at the nurse’s station, and the resident reported being unable to get help when calling for assistance.
A resident with paraplegia and stool incontinence was left to eat lunch before being cleaned, despite telling CNA staff he could not eat with feces in his brief. In a separate event, an LVN administered meds via G-tube to a severely cognitively impaired resident while the privacy curtain was left fully open, exposing the resident to the hallway. Both events were identified as dignity and privacy failures by facility leadership.
Nonfunctional Closet Drawer: A resident with severe cognitive impairment and dependence for multiple ADLs had a broken closet drawer that was hanging down and had a broken handle, making it nonfunctional. RN observed the issue and stated broken drawers should be addressed promptly to support a homelike environment, dignity, and safe storage of personal belongings; the DON also stated broken furniture should be reported to maintenance immediately.
Unnecessary Psychotropic Medication Monitoring Deficiency: A resident with dementia, anxiety disorder, and fluctuating decision-making capacity received a PRN lorazepam order for anxiety manifested by increased restlessness leading to shortness of breath, with non-pharmacological interventions listed before use. The ADON stated there was no care plan or order for monitoring the medication’s black box warning adverse effects or for behavioral monitoring to show whether the medication was effective or needed adjustment, despite the facility policy requiring monitoring and documentation of response to psychotropic meds.
Failure to Timely Report Unwitnessed Fall With Injury of Unknown Origin: A resident with severe cognitive impairment, osteoporosis, and high fall risk was found on the floor next to the bed with facial bleeding and multiple lacerations requiring sutures after an unwitnessed fall. RN and LVN staff described finding the resident and calling 911 for hospital transfer, and the DON stated no staff directly observed how the injuries occurred. The DON also stated the incident was not reported to the SA as required by policy for suspected abuse, neglect, or injury of unknown source.
A resident with COPD, dysphagia, and generalized weakness had an OSR for oxygen at 2 L/min via N/C, but the care plan still directed continuous oxygen at 4 L via N/C. RN and DON acknowledged the care plan did not match the current physician order, and the facility policy stated care plans are revised as resident conditions change.
Failure to Rotate Insulin Injection Sites: Licensed nursing staff did not rotate SQ insulin injection sites for two residents with DM, despite provider orders, care plan interventions, and facility policy requiring site rotation. Record review showed repeated injections in the same abdominal quadrants for both residents, and the DSD and DON confirmed that staff did not follow the insulin administration policy or manufacturer instructions.
Failure to Follow Up After Ophthalmology Appointment: A resident with DM, impaired vision, and moderate cognitive impairment reported weeks of left eye dryness and pain, saying he had told multiple staff and requested eye drops but felt ignored. Records showed an ophthalmology visit for bilateral eye pain, floaters, and blurry vision, but there was no documentation that the resident returned from the appointment or that any visit note or new orders were received and carried out. Staff confirmed the lack of follow-up documentation and that the resident's eye complaints were not addressed.
Failure to notify the physician and assess repeated splint refusals: A resident with hemiplegia and hemiparesis had orders for a right hand splint and right elbow splint for contracture management, but was observed without the splints and staff reported the resident had long-standing refusals because they were painful. RNA staff and the ADON confirmed there was no SBAR documentation for the refusals, and the physician was not notified.
Failure to Complete Monthly Weight Loss Assessment and Update Care Plan: A resident with GERD, major depressive disorder, a stage 4 sacral pressure ulcer, and impaired cognition had documented significant weight loss and required set-up assistance with eating. The RD identified an 11.4% weight loss over 3 months, but the monthly weight loss assessment was not completed on the first of the month and the care plan was not updated to reflect the resident’s current weight loss, despite existing orders for RD review, weekly weights, and monitoring for significant weight change.
A resident with intact cognition and a need for setup or clean-up assistance with eating requested teeth and was seen by the dentist, who recommended tooth extractions and new dentures/partials. The SSA later acknowledged there was no follow-up after the dental visit and that she overlooked the resident’s dental needs. The DSD and DON stated social services was responsible for dental scheduling and that the lack of timely follow-up delayed denture fitting.
A resident with intact cognition and a history including UTI, bacteremia, and pneumonia poured water from the top of a med cart during med pass while an LVN, another LVN, and an RN were present at Station 2 desk. The staff did not stop or educate the resident at the time, and later stated residents should not touch or pour liquids from medication carts because it is an infection control issue and can contaminate items used for medication administration.
A resident with parkinsonism, aphasia, generalized muscle weakness, and moderately impaired cognition had a hospital CM inquire about discharge back to the facility. The AA spoke with the CM and stated the facility would accept the resident once candida auris test results were available to arrange appropriate isolation, but this conversation was never documented in the resident’s progress notes. The ADON was unaware of the resident’s potential return and stated the communication should have been charted to support IDT communication and an accurate record, and review of the facility’s documentation policy with the DON confirmed that such services and changes must be completely and accurately recorded.
Surveyors found that two emergency exit doors and their egress paths were obstructed by items including a signage board, a wheelchair, and a floor cleaner machine in separate hallways between resident rooms and common areas. An LVN and the Operations Assistant acknowledged that hallways to emergency exits should be kept clear, and the DON confirmed that blocked exits could delay emergency response and endanger staff and residents. Review of the facility’s “Exits or Means of Egress” policy showed it required exits to remain clear at all times and never be blocked, even briefly, which was not followed.
A resident with psychosis and a history of falls received quetiapine for delusions, but nursing staff failed to perform ordered weekly orthostatic BP checks related to this antipsychotic, documenting them as "not applicable" on multiple occasions. The resident’s H&P documented lack of decision-making capacity, yet verbal consent for quetiapine was obtained from the resident rather than the responsible party. Later, the total daily quetiapine dose was increased from 100 mg to 150 mg without obtaining new informed consent from the representative, despite facility policy requiring consent prior to initiating or increasing psychotropic medications. The DON and ADON acknowledged that physician orders and facility policies on psychotropic use, monitoring, and informed consent were not followed.
A resident with orthopedic aftercare, COPD, and respiratory failure had PRN orders for hydrocodone-acetaminophen for moderate pain (4–6) and oxycodone-acetaminophen for severe pain (7–10). Review of the MAR and interviews showed that on multiple occasions nurses administered hydrocodone when the resident’s documented pain level was 7 or 8, instead of giving the ordered oxycodone for severe pain. The ADON and DON confirmed that staff did not follow the physician’s pain management orders, despite facility policies requiring medications to be administered as prescribed.
Two residents did not receive appropriate person-centered care planning and implementation. One resident with COPD and respiratory failure had a continuous oxygen order but was observed asleep with the nasal cannula disconnected while the concentrator was running, and staff and record review confirmed there was no care plan addressing the resident’s removal or refusal of oxygen. Another resident with osteoarthritis, morbid obesity, and high fall risk had a care plan requiring the bed to be kept in a low position, yet was observed asleep with the bed in a high position, and staff confirmed there was no care plan reflecting the resident’s preference for a high bed despite the documented fall risk.
A high fall-risk resident with osteoarthritis, morbid obesity, and right knee pain, who required moderate assistance for toileting and lower body dressing, was found asleep in a bed left in a high position despite a care plan intervention requiring the bed to be kept low with brakes locked. The resident’s fall risk assessment identified them as high risk, and their cognitive skills for daily decisions were documented as intact. During interviews, the ADON and DON acknowledged there was no care plan addressing the resident’s preference for a high bed position and confirmed that the facility’s fall prevention policy required identification of interventions based on assessment, which had not been done in this case.
A resident with COPD and acute and chronic respiratory failure with hypoxia had physician orders for continuous oxygen via nasal cannula, which were revised to 2 L/min. During observation, the oxygen concentrator was found running at 5 L/min while the nasal cannula was not connected to the resident but hanging on nearby equipment. An RN confirmed the oxygen setting and disconnection, and an LVN obtained a pulse oximeter reading of 92% before reconnecting the cannula, noting the resident’s saturations had fluctuated between 80–90% on 5 L/min. The ADON and DON confirmed there was no order to increase or titrate oxygen above 2 L/min and that facility policy requires oxygen, treated as a medication, to be administered according to prescriber orders and with proper flow, which did not occur in this instance.
A resident with orthopedic aftercare needs, psychosis, and a history of falls was admitted and assessed as using antipsychotic medication, with documentation inconsistencies between the H&P and MDS regarding decision-making capacity. Shortly after admission, the resident’s family member reported finding pills in a clear plastic bag and showed a photo of these pills to an SSA, stating the resident had been caught with pills in a GACH. The SSA acknowledged discussing the medications and viewing the photo but did not document this conversation or concern in the resident’s medical record, despite facility policy requiring documentation of events, incidents, and changes in condition to ensure a complete and accurate record.
Surveyors found that a resident with COPD and acute and chronic respiratory failure receiving O2 via concentrator had nasal cannula tubing hanging from a portable emergency light with the tubing touching the floor, while the resident was asleep and not connected to the cannula. Documentation showed the resident lacked decision-making capacity in the H&P but had intact cognitive skills on the MDS and required staff supervision for ADLs. The ADON stated O2 tubing should not touch the floor for infection control, and the DON acknowledged the risk of infection and reported there was no specific written policy, only a facility practice to keep O2 tubing off the floor.
The facility failed to maintain an effective, on-going pest control program that included routine interior inspections and treatment. Two residents with multiple medical conditions and intact cognition reported seeing cockroaches in their rooms and nearby hallways on several occasions, with staff responding by killing the insects on sight and discarding them. Review of pest control logs and interviews with the Maintenance Supervisor and the pest control contractor showed that only the exterior of the building received scheduled monthly inspections and treatment, while the interior was inspected only when specific pest complaints were reported, contrary to the facility’s own pest control policy stating the building would be kept free of insects and rodents.
A resident with paraplegia, osteoarthritis of the hip, a stage 4 sacral pressure ulcer, and fluctuating decision-making capacity was documented on the MDS as fully dependent on staff for hygiene, dressing, and transfers. However, Fall Risk Observation/Assessment forms completed by staff indicated the resident had no neuromuscular or functional conditions or risk factors such as loss of limb movement. During an interview and record review, the DON confirmed these fall risk assessments were incomplete and failed to include the resident’s paraplegia, resulting in a lower fall risk score, contrary to the facility’s policy requiring complete and accurate medical record documentation.
A nurse documented the administration of apixaban for a resident with multiple serious conditions, even though the medication was not actually given and remained in the medication packaging. The resident was out for dialysis at the time, and there was no nursing note explaining the discrepancy. Facility leadership confirmed the documentation was inaccurate and did not align with policy requiring complete and accurate medical records.
Staff did not consistently address a resident by their preferred name, with an LVN repeatedly using the term "honey" instead. Additionally, several CNAs and an Occupational Therapist were observed speaking in a non-English dialect in hallways near resident rooms, contrary to facility policy requiring English communication in resident areas. These actions did not align with the facility's policies on dignity and communication courtesy.
A resident with diabetes and hypertension was found with a nasal spray on the bedside table, which had not been assessed for self-administration by the interdisciplinary team. The medication was brought in by family and used by the resident without staff knowledge. Facility staff confirmed the medication was accessible and not stored securely, contrary to policy requiring assessment and secure storage of self-administered medications.
A resident with severe cognitive impairment and multiple medical conditions was not given a prescribed dose of fluconazole on the day of readmission due to miscommunication and lack of order clarification between nursing staff and the discharging hospital. The antibiotic was available, but staff incorrectly assumed the first dose had already been administered, resulting in a delay in treatment.
A resident with a history of falls and requiring moderate ADL assistance was found to have a nonfunctional call light since admission, confirmed by both the resident and an LVN. The resident had to use a roommate's call light to request help, and the DON acknowledged the importance of a working call system for timely staff response. Facility policy requires the call system to be functional and routinely maintained.
A portable AC unit was installed and operated in a resident room without obtaining required written authorization from HCAI or notifying the Department of Licensing/Certification. Maintenance and administrative staff confirmed the installation was done at a resident's request due to hot weather, and no permit or approval was sought prior to use. Facility policies required adherence to safety regulations and outlined conditions for portable HVAC use, but these were not followed.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with multiple medical conditions, including Parkinson's Disease and shortness of breath, received oxygen therapy for several days without a physician's order following readmission from a hospital. Staff and facility policy confirmed that a physician order is required for oxygen administration, but none was present in the resident's records during this time.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a lack of systematic measures to address infection risks for residents and staff.
A resident with end stage renal failure and hypertension, requiring moderate ADL assistance, was assisted to the floor by a student nurse during a transfer without facility staff supervision. The incident was not immediately documented or assessed by facility staff, despite policies and agreements requiring direct supervision of nursing students by licensed personnel.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with multiple chronic conditions received oxygen therapy without a physician's order, and staff failed to date and change the oxygen tubing and humidifier bottle as required. The humidifier bottle was found empty during use, and no supplies bag was provided for storing the oxygen tubing. Both the LVN and DON confirmed these deficiencies, which were not in accordance with facility policy.
A resident's medical records were found to be incomplete and inaccurate, with an LVN documenting CIC monitoring with the wrong date, and CNAs failing to consistently record meal intake percentages and bladder continence status. Both an RN and the DON confirmed that required documentation was missing or incorrect, contrary to facility policy.
A resident with multiple chronic conditions and high fall risk was found with their call light on the floor and out of reach, despite care plans and facility policy requiring it to be accessible. Both an LVN and the DON confirmed the call light was not within reach, which could delay needed assistance.
Failure to Care Plan for Anticoagulant Use and Self-Injurious Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident's use of aspirin and self-injurious behavior. The resident was admitted with diagnoses including cerebral ischemia, muscle weakness, and a history of falling, and had a physician's order for daily aspirin 81 mg for cerebrovascular accident. An MDS assessment showed the resident could understand and be understood and required varying levels of assistance with ADLs such as dressing, toileting, showering, and hygiene. An SBAR communication form documented that the resident was noted with discoloration to the chin and forehead, with no known fall. During interviews, an RN reported being informed of the discoloration by an LVN and completing an SBAR because the cause was unknown, stating it did not appear the resident was hit and suggesting it might have occurred during repositioning or when the resident became combative. The ADON confirmed the discoloration was noted without any known fall, acknowledged the resident was on anticoagulant medication and had a history of agitation, and stated there were no care plans related to agitation, restlessness, behaviors, or aspirin use. The DON similarly stated the resident had a tendency to hurt herself and was on anticoagulant medication, but there were no care plans for behavior or anticoagulant use. This was inconsistent with the facility’s policy requiring a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs.
Inaccurate Clinical Documentation for Falls and Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and objective medical records for two residents, resulting in inaccurate documentation in their charts. For one resident with cerebral ischemia, muscle weakness, a history of falling, and a prior CVA treated with daily aspirin, the admission record showed admission and readmission dates and the MDS documented that the resident could understand and be understood and required varying levels of assistance with ADLs. An SBAR form dated 3/30/2026 noted discoloration on the resident’s chin and forehead. However, a medical practitioner narrative progress note dated 4/2/2026 stated that the resident had a recent fall resulting in a left shoulder dislocation, bruising to the chin, and a bump on the forehead, even though facility leadership later confirmed that the resident had not had a fall, making the note inaccurate. For another resident with dementia, difficulty walking, and severe protein-calorie malnutrition, the MDS indicated the resident could understand and be understood and required supervision or assistance with several ADLs while being independent with eating and oral hygiene. An SBAR form dated 4/2/2026 documented that the resident had a fall, was last seen sleeping in bed by a CNA and then found on the floor two minutes later, and that the physician was notified with a recommendation for an X-ray of the right arm and elbow. The nurse who completed the SBAR initially stated that the physician recommended an X-ray but, upon review, acknowledged that she had documented the X-ray recommendation before actually communicating with the physician and that the X-ray recommendation was her own assumption, not the physician’s order. Review of the physician orders confirmed there was no X-ray order, and no progress note was entered to correct the inaccurate SBAR entry. The same resident’s care plan for a witnessed fall, initiated on 4/2/2026, directed staff to keep the bed in a low position with brakes locked and the call light within reach and labeled the event as a witnessed fall. However, the SBAR indicated that the CNA found the resident on the floor after last seeing the resident sleeping in bed, and the DON later stated that the CNA had actually witnessed the fall. The ADON and DON both identified that the SBAR and the care plan did not coincide regarding whether the fall was witnessed or unwitnessed, and that the SBAR inaccurately reflected that the physician had ordered an X-ray. The facility’s charting and documentation policy required that documentation in the medical record be objective, complete, and accurate, which was not followed in these instances.
Failure to Provide Advance Directive Information and Documentation
Penalty
Summary
The facility failed to inform and provide written information to adult residents about the right to accept or refuse medical and surgical treatment and the option to formulate an advance directive. The deficiency involved four sampled residents: Resident 14, Resident 10, Resident 17, and Resident 150. The report states that the Social Services Director (SSD) did not provide written advance directive information, and in several cases the advance directive documentation was incomplete or absent. Resident 14 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, dysphagia following cerebral infarction, and essential hypertension. The H&P dated 3/5/2026 indicated the resident did not have capacity to understand and make decisions, while the MDS dated 2/18/2026 indicated the resident could make self-understood and understand others and had modified independence with some difficulty in new situations only. During review of the electronic record, RN 3 stated the resident’s advance directive was not seen in PCC. SSA 1 stated the advance directive or acknowledgment form was not completed or not in PCC, and the DON stated the resident should be asked upon admission and, if no advance directive is available, social services offers the resident the opportunity to formulate one. Resident 10 was admitted with diagnoses including generalized muscle weakness, Alzheimer’s disease, depression, and anemia. The H&P dated 2/25/2026 indicated the resident had capacity to understand and make decisions, while the MDS indicated moderate cognitive impairment and substantial or maximal assistance with ADLs. The AD/POLST acknowledgment dated 9/11/2025 was incomplete and indicated the resident did not wish to do an advance directive on the day of admission, but there was no signature showing acknowledgment of the refusal. The SSD stated there was no indication or documentation that Resident 10 was given information about advance directives, and that the resident should have been given that information to clarify appropriate actions if health deteriorated. Resident 17 was admitted with diagnoses including muscle weakness, generalized anxiety disorder, and adult failure to thrive. The H&P dated 4/03/2026 indicated fluctuating capacity to understand and make decisions, and the MDS indicated the resident could understand others and be understood and needed partial to moderate assistance with ADLs. The AD/POLST form dated 9/11/2025 was incomplete, and the SSD stated there was no indication or documentation that Resident 17 was given information about advance directives. Resident 150 was admitted with diagnoses including traumatic hemothorax, difficulty walking, and muscle weakness. The MDS indicated moderate cognitive impairment and substantial/maximal assistance with ADLs. During review, the SSD stated Resident 150 refused to sign an advance directive form upon admission because the resident wanted family involvement, but there was no note documenting that request and no follow-up call to the family representative. The SSD stated Resident 150 did not have an advance directive and that the importance of having one is to ensure clarity regarding appropriate actions if the resident’s health declines or deteriorates.
Failure to Document and Assess Physical Restraint Use
Penalty
Summary
The facility failed to ensure four sampled residents were free from the use of physical restraints without the required documentation and assessment for the restraint methods being used. The report identified restraint use as placing a bed against the wall for three residents and tucking a pillow under the sheets for one resident. For each of these residents, surveyors found missing or incomplete physician orders, informed consent, restraint assessments, and care plans related to the restraint use. Resident 142 was admitted with diagnoses including muscle weakness, difficulty walking, and glaucoma. The resident’s MDS showed moderate cognitive impairment, visual impairment, and need for partial assistance with mobility and ADLs. Surveyors observed the resident’s bed placed against the wall on the right side. The OSR did not show an order for the bed placement, and staff interviews confirmed that the bed against the wall was considered a restraint. RN 7, the DSD, and the DON each stated that a physician’s order, informed consent, restraint assessment, and care plan were required, and the DSD confirmed those elements were not present for this resident. Resident 264 had diagnoses including hemiplegia, hemiparesis, muscle weakness, and age-related nuclear cataract, with fluctuating decision-making capacity, highly impaired vision, moderate cognitive impairment, and dependence to partial assistance with mobility and ADLs. Surveyors observed the resident’s bed placed against the wall. The OSR did not show an order for the restraint, the BRERO did not include an assessment for bed placement against the wall, and staff stated there was no specific assessment for that positioning. The DSD and DON stated the resident did not have the required physician’s order, informed consent, restraint assessment, or care plan for the bed placement. Resident 86 had diagnoses including difficulty walking, cognitive communication deficit, history of falling, and unspecified dementia. The resident’s H&P indicated capacity to understand and make decisions, and the MDS showed the resident could make self-understood and understand others. Surveyors observed the resident’s bed against the wall on one date, and staff later reviewed a photo showing the same positioning. LVN 7 stated there was no assessment, consent, MD order, or care plan for the bed placement. Resident 80 had diagnoses including morbid obesity, depression, and venous insufficiency, with intact cognition and dependence to set-up assistance for mobility and ADLs. Surveyors observed a pillow tucked under the sheet at the right side of the resident, and LVN 1 stated this limited the resident to one side and was a form of restraint. The OSR did not show an order for pillows tucked under the sheets, and the DSD and DON confirmed the absence of a physician’s order, informed consent, restraint assessment, and care plan for that practice.
Failure to Care Plan Lorazepam Use and Hot/Cold Gel Pack Self-Administration
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 175 related to lorazepam use. Resident 175 was admitted with diagnoses including dementia, anxiety disorder, and type 2 DM, and the H&P noted fluctuating capacity to understand and make decisions. A physician order dated 4/20/2026 directed lorazepam oral concentrate 2 mg/ml, 0.5 ml sublingually every 4 hours as needed for anxiety manifested by increased restlessness leading to shortness of breath for 14 days. During a concurrent interview and record review, the ADON stated there was no care plan developed for the use of lorazepam and no physician order for monitoring the black box warning for lorazepam, including adverse effects. The ADON stated the adverse effects to be monitored included drowsiness, slurred speech, dizziness, nausea, and aggressive/impulsive behavior. The ADON also stated licensed staff should have developed a care plan for the use of lorazepam, its adverse effects, and should have monitored Resident 175 for risks, medication dependence, and withdrawal reactions. The record review and interview showed that these elements were not documented in the resident’s care plan. The facility also failed to develop a comprehensive person-centered care plan for Resident 5 regarding self-administration of a hot/cold gel pack. Resident 5 had diagnoses including polyneuropathy, hypertension, chronic pain syndrome, and COPD, and the H&P indicated the resident had capacity to make decisions. The MDS indicated intact cognitive skills for daily decision making, but also showed dependence with lower body dressing and footwear and substantial/maximal assistance with toileting hygiene and shower self. Progress notes dated 4/20/2026 and 4/21/2026 indicated the resident was being monitored for self-administration of the hot/cold gel pack, yet LVN 3 stated there was no physician order allowing self-administration and no comprehensive, person-centered care plan addressing it.
Unsafe bedside items, bed height, and equipment hazards
Penalty
Summary
The facility failed to keep medications and biologicals from being left at a resident’s bedside. Resident 163 was admitted and later readmitted with diagnoses including metabolic encephalopathy, major depressive disorder, and anxiety disorder. The resident’s record showed intact cognition and that the resident did not want to self-administer medications. The order summary did not include orders for Visine or A&D ointment, yet during observation two bottles of Visine eye drops and multiple packets of A&D ointment were found at the bedside. LVN 8 and the DSD both stated the resident was not desiring to self-administer medications and there was no order for those items, and the DON stated licensed staff should not have left medications at the bedside. The facility also failed to keep a resident’s bed in the lowest position. Resident 159 was admitted and readmitted with diagnoses including dementia, muscle wasting, atrophy, and lack of coordination. The resident’s history and physical noted fluctuating capacity to understand and make decisions, and the MDS indicated severe cognitive impairment and need for substantial to partial assistance with mobility and ADLs. The resident was assessed as a moderate fall risk, and the care plan included keeping the bed in the lowest position. During observation, the bed was found in a high position and measured 27 inches from the floor to the mattress surface. Staff stated the bed was too high and that the care plan called for the lowest position. The facility further failed to maintain safe resident equipment and floor mat interventions. Resident 231, who had dementia, age-related osteoporosis, and a history of falling, was observed with a call light cord that had frayed and exposed wires. CNA 10 and the DON stated exposed wires should not be present because of the potential for electrocution. Resident 239 and Resident 255 were both assessed as fall risks and had care plans that included floor mats on one side of the bed. In both rooms, the bedside table was observed placed on top of the floor mat. CNA 8, RN 5, and the DON stated the table should not be on the mat because the mat is intended to cushion a fall and the table interfered with that purpose.
Urinary catheter and urinal care not followed
Penalty
Summary
The facility failed to ensure appropriate care for residents with urinary catheters and urinary incontinence for three sampled residents. One resident who was always incontinent of urine had an unlabeled urinal sitting on the bedside drawer. The resident’s care plan identified a risk for urinary tract infection, and the Director of Staff Development stated the urinal should have been labeled with the resident’s name, room number, and date it was provided, but it was not. The Director of Nursing stated the unlabeled urinal could be used by another resident and that labeling was used to prevent UTI. A second resident with an indwelling urinary catheter did not have a securement device in place. The resident’s orders required daily catheter care and use of a stabilization device to secure the catheter, and the care plan also directed staff to use a catheter anchor. During observation, the catheter was seen without a stat lock or leg strap. The Director of Staff Development stated the licensed staff did not follow the physician’s orders and facility policies requiring a securement device, and the Director of Nursing stated the catheter should have been secured to prevent tugging and pulling. A third resident with an indwelling catheter order for 16 Fr/10 cc was observed with a 20 Fr catheter. The resident had diagnoses including neuromuscular dysfunction of the bladder, bacteremia, and paraplegia. Staff documented that the resident had bypassing of the Foley catheter, and treatment staff attempted to replace the catheter but met resistance and were unsuccessful. The treatment nurse stated the resident had been found with a 20 Fr catheter and that the order was for 16 Fr. The Assistant Director of Nursing stated there was no documentation showing that a 20 Fr catheter had been ordered or placed, and that the physician order and policy were not followed.
Respiratory Care Errors Involving Suction Equipment, Oxygen Tubing, and Oxygen Orders
Penalty
Summary
Resident 22, who had diagnoses including COPD and dyspnea and was documented as lacking capacity to understand and make decisions, was observed with an unlabeled suction canister at the bedside suction setup. During the observation, RN 8 stated the canister should have been labeled with the date and time it was provided for infection control. The facility’s DSD and DON also stated the canister should have been labeled with the date it was provided and that the canisters should be changed weekly, but the canister observed at the bedside was not labeled as required by the facility policy. Resident 235, who had diagnoses including COPD and CHF and was documented as cognitively intact, was observed asleep in the room with oxygen therapy running at 2 liters per minute via NC while the tubing was touching the floor. CNA 5 stated the tubing should not touch the floor and should be kept off the floor by placing extra tubing inside the plastic storage bag on the side of the oxygen concentrator. LVN 11 and the DON also stated the tubing should not have been touching the floor and that extra tubing should be placed in the storage bag, but the observation showed the tubing on the floor. Resident 5, who had diagnoses including polyneuropathy, hypertension, chronic pain syndrome, and COPD and was cognitively intact, was receiving oxygen at 5 liters per minute via NC. The physician’s order indicated oxygen at 2 to 5 liters per minute via NC continuously every shift, but LVN 3 stated the oxygen therapy care plan and order did not include oxygen titration parameters with a specific target saturation level and did not document pulse oximetry frequency. The DON stated the absence of those details could result in inadequate respiratory monitoring and improper oxygen administration. Resident 212, who had diagnoses including COPD, dysphagia, oropharyngeal phase, and generalized muscle weakness and was documented as having intact cognition, had an order for oxygen at 2 liters per minute via NC continuously every shift. During observation, LVN 10 found the oxygen concentrator set at 4.5 liters per minute. After reviewing the order, LVN 10 stated the resident was receiving the incorrect oxygen level and adjusted it to 2 liters per minute. The DON stated the order was not being followed and that the resident could have had over oxygenation.
Bed rails used without required orders, consent, assessments, and care plans
Penalty
Summary
The facility failed to safely use bed rails for three sampled residents by not ensuring the required physician orders, informed consent, bed rail assessments, and care plans were in place for the specific bed rail use observed. The report states that the facility used bed rails without meeting its own criteria for use, and that staff and leadership acknowledged the need for a resident assessment, entrapment assessment, consent, physician order, and care plan before bed rails are used. Resident 11 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, type II DM, and generalized muscle weakness. The H&P noted fluctuating capacity to understand and make decisions. The MDS showed the resident needed supervision or touching assistance with toileting, personal hygiene, showering, and lower body dressing, and was independent with rolling and sit-to-lying. During observation, the resident was seen in bed with bilateral side rails elevated, and CNA 4 stated the resident requested the side rails be elevated at all times. RN 5 reviewed the record and stated there was no current physician order for side rail use and no care plan documented for side rail use. The DON stated side rail use required assessment for risks and benefits, entrapment assessment, consent, a physician order, and inclusion in the comprehensive person-centered care plan. Resident 22 had diagnoses including Alzheimer's disease, contracture, and seizures, and the H&P stated the resident did not have capacity to understand and make decisions. The MDS indicated severely impaired cognition and dependence for mobility and ADLs. The OSR contained an order for padded side rails up times 2 top of quarter for mobility/enabler every shift for seizures, and the BRERO assessed quarter rails. However, during observation the resident's bed rails were identified as 1/2 length. The DSD stated the resident had an order for 1/4 padded side rails/bedrails but no order for the 1/2 bed rails actually in use, and that the BRERO and consent were for a 1/4 bed rail. Resident 163 had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and disorders of bone density and structure of the left hand. The MDS showed intact cognition and dependence to partial assistance with mobility and ADLs. The OSR ordered may have 1/4 side rails up x 2 for mobility aid, and the BROA assessed bilateral 1/4 bedrails, but the DSD stated the resident was on 1/2 bed rails without a specific order, informed consent, bed rail assessment, or care plan for that use.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous insulin administration sites for three of three sampled residents. The report states that the medication error involved preparation or administration of insulin that was not in accordance with the prescriber’s order, manufacturer’s specifications, and accepted professional standards. The deficiency was identified through interview and record review for residents receiving insulin therapy. One resident was admitted with diagnoses including type 2 diabetes mellitus and mild protein-calorie malnutrition. The resident’s orders included insulin with instructions to rotate injection sites, and the care plan also identified a potential for skin discoloration related to insulin injections with an intervention to rotate injection sites regularly. The location of administration record for March 2026 showed insulin was administered subcutaneously, and the Director of Staff Development stated there were multiple instances where licensed staff did not rotate the insulin administration sites. The DSD stated that rotating sites was important to prevent bruising and lipodystrophy and that administering insulin on sites of lipodystrophy could affect absorption and cause hypo- or hyperglycemia. A second resident with diagnoses including DM2 with diabetic neuropathy and morbid obesity had orders for NovoLog and facility-provided manufacturer information that directed injection site rotation within the same region to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. A third resident with diagnoses including DM2 and dementia had orders for Humulin R and insulin glargine that specifically directed rotation of injection sites. Review of the location of administration records showed repeated use of the same abdominal quadrant and repeated use of the left arm without rotation. The DSD and DON both stated that the insulin administration sites were not rotated, that insulin is a significant medication, and that failure to rotate sites was considered a medication error because it did not follow the physician’s order, manufacturer’s guidelines, and standards of practice.
Fortified Diets Not Prepared as Ordered During Lunch Service
Penalty
Summary
The facility failed to meet the nutritional needs of 38 out of 237 residents who received fortified diets when, during lunch trayline service, Cook 2 did not follow the fortified diet instructions posted at the trayline station. The menu spreadsheet for the regular diet listed diced fried potatoes and Capri blend vegetables with 1 teaspoon of margarine, while the fortified diet instructions required adding 1 oz of melted margarine to potatoes, rice, pasta, and hot vegetables to increase calorie density for residents who could not consume adequate calories and/or protein to maintain weight or nutritional status. During trayline observation, Cook 2 was observed using a household teaspoon to add melted margarine to the diced fried potatoes and Capri blend vegetables for residents on fortified diets. In interview, Cook 2 stated she used a household teaspoon and had only used one to two teaspoons of melted margarine for fortified diets. The Dietary Supervisor stated that the fortified diet instructions required 1 oz of melted margarine, equivalent to 30 ml, and that Cook 2 should have used the correct scoop or ladle. The Dietary Supervisor later stated that Cook 2 did not use the correct scoop when adding melted margarine during lunch service and that the residents receiving fortified diets were at risk for weight loss due to decreased calorie density in their food. The DON also reviewed the fortified diet information and stated that kitchen staff were supposed to follow and prepare residents' meals as indicated in the menu, and that using the appropriate scoops or ladles would ensure residents received the correct number of calories and nutrients they needed.
Unsafe Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. During an initial kitchen tour, eight meal trays were observed stacked and still wet in the drying area next to the dishwashing area, and two clear food storage bins were observed stacked and still wet in the dried food storage bins area. The Dietary Supervisor stated that dishes, meal trays, food storage bins, pots, and pans should not be stacked while still wet and should be air dried before stacking. In the dry food storage room, four onions with green sprouts and four onions with brown and dark gray discoloration that were soft to touch were observed inside a brown box. One dented can of fruit cocktail was also observed mixed in with non-dented cans. The Dietary Manager stated that the sprouted and discolored onions should have been discarded and that the dented can should have been removed from the non-dented cans and placed in the designated area for dented cans. In the walk-in refrigerator, one container of soy milk, one container of almond milk, and one container of liquid non-dairy creamer were observed without open dates. In the tray area, four plastic bags of hotdog buns and two plastic bags of hamburger buns had stickers showing the received date, but no open date was indicated. The Dietary Supervisor stated that opened food items should be labeled with the date they were opened so staff would know they were not old. Facility policies and food storage guidance reviewed by surveyors indicated that food items in storage and refrigeration should be labeled and dated, and that reusable dishware and equipment should be air dried only.
Antibiotic Stewardship Monitoring and Order Deficiencies
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for three sampled residents by not consistently monitoring antibiotic use and adverse effects, and by not ensuring antibiotic orders contained complete and appropriate information. The report states that the facility’s policies required antibiotic orders to include the drug name, dose, frequency, route, and indication, and that residents receiving antibiotics were to be monitored for adverse effects every shift and documented in the progress notes. For one resident admitted with chronic pulmonary edema and emphysema, Augmentin was ordered for bacterial pleural effusion for 10 days. The care plan identified possible adverse effects such as diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions, with monitoring every shift. During record review, the Director of Staff Development found missing progress note monitoring on multiple dates while the resident was receiving the antibiotic, and stated the monitoring was not consistently completed every shift. For another resident with obstructive and reflux uropathy and chronic embolism/thrombosis, Hiprex was ordered for UTI prevention without an end date, and Cefuroxime Axetil was ordered for left hand swelling. The care plan included monitoring for adverse effects every shift, but the progress notes did not consistently show this monitoring. The DSD and DON stated the Hiprex order lacked a duration, the Cefuroxime indication was a symptom rather than a diagnosis, and there was no evidence of consistent adverse-effect monitoring. For a third resident admitted with MRSA infection in the blood, Daptomycin was ordered intravenously every 24 hours for 8 weeks. The care plan directed staff to monitor for adverse reactions every shift, but the progress notes from the start of therapy through the review period did not show monitoring for adverse side effects. The IP and DON both stated that licensed nurses were supposed to monitor residents on antibiotics every shift and document those observations in the progress notes.
Frayed bed remotes and nonfunctioning call light
Penalty
Summary
The facility failed to maintain resident care equipment in safe operating condition when bed remote controls for three residents were observed with frayed and exposed wires near the control pad. Resident 49 was admitted with diagnoses including difficulty walking, muscle weakness, and spondylopathy of the lumbosacral region. The resident’s record showed the resident had the capacity to understand and make decisions at admission, while the MDS later indicated severe cognitive impairment and dependence for mobility and ADLs. During observation in the resident’s room, the bed remote control had peeling wires that were frayed and exposed, and the RNA stated the remote should have no exposed wires to prevent electrocution. Resident 136 was admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and restlessness and agitation. The resident’s H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS showed severe cognitive impairment, dependence for mobility and ADLs, and high fall risk. During observation in the resident’s room, the bed remote had peeling and exposed wires near the control pad. The CNA stated there should be no exposed electrical wires in the resident’s environment because of the risk of accidents such as electrocution. Resident 3 was admitted and later readmitted with diagnoses including a stage four sacral pressure ulcer, paraplegia, and major depressive disorder. The resident’s H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS showed moderately impaired cognition and dependence for mobility and ADLs. During observation in the resident’s room, the bed remote control had frayed and exposed wires near the control pad, and the CNA stated there should be no exposed electrical wires to prevent accidents such as electrocution. The CNA also attempted to use the bed remote to elevate the bed for care, but the remote was not working. The facility also failed to maintain the resident call system in functional condition for Resident 41, who was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, essential hypertension, and morbid obesity. The MDS showed the resident could make self-understood and understand others, had moderate cognitive impairment, and needed maximal assistance with mobility and ADLs. The resident stated the resident had been calling to be changed but no one would go to the room. When the resident pressed the call light, the light outside the room did not illuminate or ring at the nurse’s station. CNA 7 and ADON 2 observed the same malfunction, and CNA 7 stated the resident would not be able to call for assistance if the call light was not working.
Dignity and Privacy Failures During Meal and G-Tube Care
Penalty
Summary
Resident 3 was observed eating lunch in bed while his incontinence brief had not been changed and he had stool in the brief. During the lunch observation, the resident told CNA 3 that he needed to be cleaned before eating and stated that he could not eat with feces in his brief. CNA 3 told him to eat first and said he would be cleaned after he had eaten, while continuing to reposition him, elevate the head of the bed, and prepare the lunch tray. The DSD later observed the resident eating with the brief still unchanged and stated the brief should have been changed first because it was a dignity issue. Resident 3’s record showed diagnoses including paraplegia, a stage 4 pressure ulcer of the sacral region, and major depressive disorder. The H&P stated he did not have the capacity to understand and make decisions, while the MDS indicated he could make himself understood and understand others, had moderate cognitive impairment, was dependent or needed set-up assistance with mobility and ADLs, was frequently incontinent of stool, and was at risk for pressure injuries with one unhealed pressure injury. His care plan included a bowel/bladder program to improve or maintain continence if needed. Resident 287 was observed in the room while LVN 4 administered medications via G-tube with the privacy curtain fully open, leaving the resident exposed and visible from the hallway. LVN 4 stated that leaving the curtain open exposed the resident and violated privacy and dignity. Resident 287’s record showed diagnoses including hydrocephalus, hypertension, encephalopathy, and dysphagia, and the MDS indicated severely impaired cognition, dependence with all ADLs, and use of a feeding tube. The DON stated the privacy curtain must be closed during G-tube medication administration to protect privacy and dignity.
Nonfunctional Closet Drawer
Penalty
Summary
The facility failed to provide a homelike environment for one sampled resident by not maintaining functional closet drawers. Resident 2 was admitted on 2/21/2025 and readmitted later, with diagnoses including metabolic encephalopathy, type 2 DM, and dysphagia. The resident's MDS dated 3/2/2026 indicated severely impaired cognitive skills for daily decision making and dependence on staff for toileting hygiene, showering, lower body dressing, footwear, chair/bed-to-chair transfer, and tub/shower transfer. During a concurrent observation and interview on 4/22/2026, RN 1 observed that Resident 2's closet drawer was broken and hanging down, and stated the drawer had a broken handle and was nonfunctional. RN 1 stated broken drawers should be addressed promptly to ensure residents maintain a homelike environment, dignity, and the ability to safely store and access personal belongings. During an interview on 4/24/2026, the DON stated that broken furniture needs to be addressed to maintenance immediately and that nonfunctioning furniture can negatively affect a resident's mood and psychosocial wellbeing, potentially leading to frustration, decreased independence, and reduced quality of life. The facility's Homelike Environment policy stated that residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use personal belongings to the extent possible.
Unnecessary Psychotropic Medication Monitoring Deficiency
Penalty
Summary
The facility failed to ensure that one sampled resident with dementia, anxiety disorder, and Type II diabetes mellitus was free from unnecessary psychotropic medication use and chemical restraint concerns. Resident 175 was admitted with fluctuating capacity to understand and make decisions, and a physician order later directed lorazepam oral concentrate 2 mg/ml, 0.5 ml sublingually every 4 hours as needed for anxiety manifested by increased restlessness leading to shortness of breath for 14 days, with non-pharmacological interventions to be provided before administration. During a concurrent interview and record review, the ADON stated there was no care developed for the use of lorazepam and monitoring for its black box warning adverse effects. The ADON stated there was no order for monitoring adverse effects or behavioral monitoring for anxiety manifested by increased restlessness leading to shortness of breath, and that behavior and adverse effect monitoring should be used to determine whether the medication was effective or needed adjustment. The facility policy on psychotropic medication use stated residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record, and that residents receiving psychotropic medication are monitored and the response to treatment is documented.
Failure to Timely Report Unwitnessed Fall With Injury of Unknown Origin
Penalty
Summary
The facility failed to report an unwitnessed fall with injuries of unknown origin to the State Survey Agency immediately, and no later than two hours after the allegation, for one resident. Resident 23 was admitted with diagnoses including a displaced comminuted fracture of the left fibula, Alzheimer’s disease, and osteoporosis. The resident’s MDS showed a BIMS score of 00, indicating severe cognitive impairment, and the resident required assistance with multiple activities of daily living. The fall risk assessment identified the resident as high risk for falls. On 4/11/2026, staff found Resident 23 lying on the floor on her back next to the bed with blood on her face. RN 3 documented a bump, skin discoloration, and a skin tear on the left forehead, a skin tear on the bridge of the nose, and a skin tear above the right eyebrow. Staff called 911, and EMTs transferred the resident to the hospital. The hospital ED note identified the event as an unwitnessed fall and documented laceration repairs with sutures to the forehead, bridge of the nose, and right eyebrow. During interviews, RN 3 stated she responded to the room after being paged and found the resident on the floor with blood on her face. LVN 5 stated CNA 11 called her after observing the resident on the floor while passing by the room, and LVN 5 then found the resident on the floor and notified the RN supervisor and PCP. The DON stated the resident sustained an unwitnessed fall with lacerations requiring stitches, that no staff directly observed how the injuries occurred, and that the incident was not reported to the SA. The facility policy reviewed by the DON stated suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately according to state law.
Care Plan Did Not Match Current Oxygen Order
Penalty
Summary
The nursing staff failed to revise Resident 212’s care plan to reflect a change in the physician’s oxygen order. Resident 212 was admitted with diagnoses including COPD, dysphagia, and generalized muscle weakness, and the H&P indicated the resident had the capacity to understand and make decisions. The MDS showed the resident could make self understood and understand others, had intact cognitive function, and required partial to moderate assistance with several activities of daily living. A review of the OSR showed an order for oxygen at 2 liters per minute via nasal cannula continuously, every shift. However, the care plan still listed continuous oxygen at 4 liters via nasal cannula related to COPD, with a goal of effective airway exchange and an intervention to administer oxygen at 4L via nasal cannula. During interview and record review, RN 5 stated the care plan needed to match the OSR and that it did not, and the DON stated a care plan needed to follow the OSR and if incomplete could not meet resident needs. The facility policy stated care plans are revised as residents’ conditions change.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
Licensed nursing staff failed to rotate subcutaneous insulin administration sites for two residents, despite orders and care plan interventions directing that injection sites be rotated. The deficiency was identified during record review and interviews with the Director of Staff Development (DSD) and Director of Nursing (DON), who both stated that the staff did not follow the facility’s insulin administration policy or the manufacturers’ instructions for the insulin products used by the residents. One resident had diagnoses including type 2 DM and mild protein-calorie malnutrition, and the record showed orders for Basaglar, insulin lispro, and sliding-scale insulin with instructions to rotate injection sites. The care plan also identified a potential for skin discoloration related to insulin injections and included an intervention to rotate injection sites regularly. The location of administration record showed repeated insulin injections in the same abdominal areas on multiple occasions, including the LLQ, LUQ, and RUQ, rather than consistent rotation across sites. The second resident had diagnoses including DM with diabetic neuropathy, morbid obesity, and disease of spleen, and the record showed orders for NovoLog and Lantus with instructions to rotate insulin sites. The care plan again identified a potential for skin discoloration related to insulin injections and directed regular rotation of injection sites. The location of administration record showed repeated NovoLog injections in the same abdominal quadrants on multiple dates, including multiple injections in the LLQ, LUQ, and RLQ. The DSD stated there were multiple instances where licensed staff did not rotate the insulin administration sites for both residents, and the DON stated the staff did not follow the facility policy and manufacturer specifications.
Failure to Follow Up After Ophthalmology Appointment
Penalty
Summary
The facility failed to ensure that Resident 53 received proper treatment after an ophthalmology appointment. Resident 53 was admitted with diagnoses including diabetes mellitus, difficulty walking, and depression, and the record also noted fluctuating capacity to understand and make decisions and moderate cognitive impairment. The care plan identified impaired vision and eye-related concerns, including the need to monitor for irritation, redness, dryness, and to arrange consultation with an eye care practitioner as required. During observation and interview, Resident 53 reported dryness in the left eye for 7 weeks and described it as feeling like a scratch on the skin. The resident stated he had eye surgery in the past, had used eye drops previously, and had complained to multiple staff about the dryness and requested eye drops, but felt ignored. On concurrent interview, the resident again stated that he had informed multiple staff that nothing had been done and requested eye drops for relief. Record review and staff interviews showed that Resident 53 had an ophthalmology appointment, but there was no documentation that he returned from the appointment or that any visit note or new orders were received and carried out. LVN staff stated that the appointment result was not available in the chart and that there was no order for eye drops. The visit note from the ophthalmology appointment documented complaints of pain in both eyes, floaters, blurry vision, and pain for 6 months, with the resident using over-the-counter dry eye drops. Staff interviews also confirmed that documentation was required when residents left for and returned from appointments, and that the resident's needs were not addressed.
Failure to Notify Physician and Assess Repeated Splint Refusals
Penalty
Summary
The facility failed to provide restorative nursing services for a resident with limited ROM and mobility related to hemiplegia and hemiparesis following a cerebral infarction, seizure, and anemia. The resident was admitted with fluctuating capacity to understand and make decisions, and later assessments showed clear speech and the usual ability to understand others, with substantial/maximal assistance needed for mobility and ADLs. The resident had orders for a right resting hand splint and a right elbow splint to be applied by RNA 5 times per week for 4 to 6 hours per day or as tolerated for contracture management of the right upper extremity, with monitoring for redness, skin irritation, or discomfort. During observation, the resident was seen without the right hand and right elbow splints in place. RNA staff stated the resident had already completed ROM exercises and that the resident refused to wear the splints because they were painful. One RNA stated the resident had refused the splints for a long time and that charge nurses were aware of the refusals. The Assistant DON reviewed nursing progress notes, RNA weekly summaries, and eINTERACT SBAR documentation and stated there was no SBAR documentation for the resident's refusal to wear the splints. The ADON stated the SBAR should include assessment information such as pain, body system, mental and functional status, change in condition, notification of the clinician/doctor, notification of the family or resident representative, and any intervention orders. The ADON also stated there should have been an SBAR completed when the resident refused the splints, but there was none. The report also states the physician was not notified when the resident had constant refusals for the right hand and right elbow splints.
Failure to Complete Monthly Weight Loss Assessment and Update Care Plan
Penalty
Summary
The facility failed to recognize, evaluate, and address the nutritional needs of a resident at risk for impaired nutrition and hydration by not completing the monthly weight loss assessment as established by the interdisciplinary team. The resident was admitted with diagnoses including GERD, major depressive disorder, and a stage 4 sacral pressure ulcer, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS later indicated the resident had moderately impaired cognition, required set-up assistance with eating, and had experienced 5% or more weight loss in the last month or 10% or more in the last 6 months without a physician-prescribed weight-loss regimen. The resident’s weight record showed fluctuations, including weights of 166.2 lbs., 151.7 lbs., 151 lbs., and 162 lbs. The care plan identified the resident as at risk for weight loss and documented actual significant weight loss related to dialysis with accompanying fluid shifts. The care plan goal was to avoid significant weight change, with interventions including RD evaluation as indicated, weekly weights, and reporting significant weight changes to the physician. A dietary note later documented that the IDT reviewed the resident for a 19 lb. weight loss over 3 months, equal to 11.4%, with a height of 69 inches, weight of 151.5 lbs., BMI of 22.4, and multiple diet orders including CCHO, renal, double portions, IDDSI level 7 easy-to-chew texture, thin liquids, a sugar-free renal HS snack, and a 1200 ml/day fluid restriction. During interview, the RD stated she completed the weight loss calculation and identified the 11.4% loss but did not update the prior care plan to reflect the current weight loss. The RD stated monthly weight loss assessments should be done on the first of the month and that the care plan should have been updated after 72 hours. The DON also stated the RD should have performed the monthly assessment on the first of April and updated the care plan immediately.
Failure to Follow Up on Dental Needs and Denture Fitting
Penalty
Summary
The facility failed to follow up on a resident’s request for dentures after the resident was seen by the dentist and the dentist recommended new dentures/partials and tooth extractions. Resident 80 was admitted on 8/3/2021 and readmitted on 8/16/2023 with diagnoses including morbid obesity, type 2 DM, and disease of spleen. The resident’s H&P dated 12/5/2025 indicated the resident had the capacity to understand and make decisions, and the MDS dated 2/23/2026 indicated the resident could make self-understood and understand others, had intact cognition, and needed setup or clean-up assistance with eating. The record showed an order for dental consultation as needed, and an Onsite Mobile Dental form dated 11/21/2025 documented that the resident wanted teeth and that the dentist recommended teeth extractions and new dentures/partials. A later OMB form dated 12/12/2025 documented 12 PA x-rays but did not include a patient chief complaint or treatment recommendations. During interview and record review, the SSA stated there was no follow up after the 12/12/2025 dental visit and that she overlooked the resident’s dental needs. The DSD stated social services was responsible for scheduling dental services, that the SSA should have followed up the extraction and x-ray results to facilitate denture fitting, and that it was not appropriate to wait four months for denture fitting. The DON stated the SSA should have followed up within the same month the x-rays were done.
Resident Touched and Poured Water From Medication Cart During Med Pass
Penalty
Summary
The facility failed to implement and maintain its infection control program when Resident 153 poured a cup of water from the top of Med Cart 1 during a medication pass observation in front of Station 2 desk. Resident 153 had been admitted with diagnoses including UTI, bacteremia, and pneumonia, and the H&P and MDS indicated the resident had intact cognition, could understand and make decisions, and was able to make needs known. During the observation, Med Cart 1 and Med Cart 2 were positioned in front of Station 2 desk with LVN 2, LVN 12, and RN 1 present. Resident 153 poured water from Med Cart 1, drank from the cup, discarded it in the trash bin on the cart, and left. The staff did not educate Resident 153 at the time about not pouring or touching items on top of the medication cart. During interviews, LVN 2 stated she did not see the resident pour the water because the computer screen blocked her view, while LVN 12 and RN 1 stated they did not notice the act and could not explain why it was not observed. All three staff stated residents are not supposed to pour liquids from medication carts because it is an infection control issue and could contaminate items on top of the carts; they also stated residents may have fluid restrictions or may not be appropriate to consume thin liquids. The IP and DON both stated residents should not touch anything on top of medication carts and that the licensed nurses should have called the resident’s attention and educated him not to touch the items used for medication administration. The facility’s IPCP policy stated the program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Failure to Document Hospital Discharge Communication in Resident Medical Record
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one of three sampled residents by not documenting a key communication regarding the resident’s potential return from a general acute care hospital. The resident had been admitted with diagnoses including unspecified parkinsonism, aphasia, and generalized muscle weakness, and had documented fluctuating capacity to understand and make decisions, with an MDS indicating moderately impaired cognitive skills for daily decisions. On the day in question, the Admissions Assistant (AA) spoke with the hospital Case Manager (CM) about the resident’s discharge back to the facility and informed the CM that the facility would accept the resident once candida auris test results were received so that appropriate isolation room arrangements could be made. During interviews and record review, surveyors found no documentation of this conversation in the resident’s progress notes for that date. The AA acknowledged that the discussion with the CM was not documented and stated she had time to document it before leaving the facility but did not do so. The Assistant Director of Nursing (ADON) reported having no knowledge of whether the resident was returning and stated that the AA should have documented the conversation to ensure timely communication among departments and to maintain an accurate and complete medical record. Review of the facility’s Charting and Documentation policy with the Director of Nursing (DON) showed that all services and changes in a resident’s condition must be documented, and that documentation must be objective, complete, and accurate to facilitate communication among the IDT, underscoring that the missing entry was inconsistent with facility policy.
Obstructed Emergency Exit Doors and Egress Paths
Penalty
Summary
The deficiency involves the facility’s failure to keep designated emergency exit doors and their egress paths free from obstruction. During an observation, surveyors noted that Exit Door 2, located in Station 5’s hallway between the dayroom and the Director of Staff Development classroom, was blocked by a signage board that indicated “emergency exit only,” and there were no staff present in that hallway at the time. In a separate observation with an LVN, Exit Door 1, located in Station 2’s hallway between two resident rooms, was found blocked by a wheelchair and a floor cleaner machine. The LVN stated that the hallway leading to the emergency exit door should be clear of any equipment. In a concurrent observation and interview with the Operations Assistant, Exit Door 1 was again observed blocked by a floor cleaner machine, and the Operations Assistant stated that equipment should be kept on one side of the hallway to allow full access to emergency exit doors. During an interview and review of the facility map with the DON, the DON acknowledged that the blocked emergency exit doors had the potential to delay emergency response and pose a danger to staff and residents, and stated that emergency exit doors should be clear and open to the outside for safety during an emergency. Review of the facility’s policy titled “Exits or Means of Egress,” last reviewed on 1/27/2026, showed that the policy required all personnel to keep exits clear at all times and that exit doors are never to be blocked, even briefly, which was not followed in these instances.
Failure to Monitor Antipsychotic Side Effects and Obtain Valid Informed Consent
Penalty
Summary
The deficiency involves the facility’s failure to prevent unnecessary chemical restraint and to adequately monitor and obtain informed consent for the use of the antipsychotic medication quetiapine for one resident. The resident was admitted with diagnoses including orthopedic aftercare, unspecified psychosis, and a history of falls. The admission History and Physical dated 12/19/2025 documented that the resident did not have the capacity to understand and make decisions, while a subsequent MDS dated 12/25/2025 indicated intact cognitive skills for daily decisions and that the resident was receiving an antipsychotic. On 12/22/2025, the physician ordered quetiapine 100 mg by mouth at bedtime for psychosis manifested by delusions. The facility failed to follow physician orders for monitoring orthostatic blood pressure related to quetiapine use. An order dated 1/15/2026 required orthostatic blood pressure checks (lying and then sitting within three minutes) every Sunday, with instructions to call the physician if the systolic blood pressure changed by more than 20 mmHg or the diastolic by more than 10 mmHg. Review of the January 2026 MAR showed that on 1/18/2026 and 1/25/2026, the assigned LVN documented orthostatic blood pressure as “not applicable” for both lying and sitting positions, meaning the ordered monitoring was not performed. The ADON and DON both stated that quetiapine can cause orthostatic hypotension, that the order required weekly orthostatic blood pressure monitoring, and that failure to complete and document these assessments could delay physician notification and delay care. Facility policies on Adverse Consequences and Medication Errors and on Psychotropic Medication Use required monitoring residents for adverse consequences and documenting responses to psychotropic medications. The facility also failed to obtain appropriate informed consent for the initiation and subsequent dose increase of quetiapine. An informed consent form dated 12/19/2025 documented that the resident verbally consented to quetiapine 50 mg twice a day for agitation and aggression, verified by an RN. However, the H&P from the same date indicated the resident lacked capacity to understand and make decisions. The ADON stated the facility should have followed the H&P and clarified with the physician and informed the responsible party. On 12/22/2025, the order was clarified to quetiapine 100 mg at bedtime, and on 12/28/2025, an additional order for quetiapine 50 mg in the evening was added, resulting in a total daily dose of 150 mg from 12/28/2025 to 1/4/2026. The ADON and DON stated that when the dose of a psychotropic medication is increased, a new informed consent is required, and acknowledged that no new consent was obtained when the dose was increased to a total of 150 mg. The DON further stated that, because the resident did not have capacity, the responsible party should have provided consent, and that without valid informed consent, the responsible party’s rights were violated. Review of the facility’s Psychotropic Medication Use and Antipsychotic Medication Use policies showed requirements to inform residents or representatives of the recommendation, risks, benefits, purpose, and potential adverse consequences of antipsychotic use and to obtain documented consent prior to initiating or increasing psychotropic medications, which the DON stated were not followed.
Failure to Follow PRN Pain Medication Orders for Severe Pain
Penalty
Summary
The deficiency involves the facility’s failure to administer pain medication according to physician orders for one resident. The resident was admitted with diagnoses including orthopedic aftercare, unspecified COPD, and acute and chronic respiratory failure with hypoxia. An H&P dated 12/19/2025 indicated the resident did not have capacity to understand and make decisions, while an MDS dated 12/25/2025 documented intact cognitive skills for daily decisions, a need for supervision with hygiene, toileting, and showering, and occasionally moderate pain. Physician orders dated 1/15/2026 directed that hydrocodone-acetaminophen 5-325 mg be given every four hours as needed for moderate pain rated 4–6, and oxycodone-acetaminophen 7.5-300 mg be given every six hours as needed for severe pain rated 7–10. Review of the MAR for January 2026 showed that LVN 2, LVN 3, and LVN 4 administered hydrocodone instead of the ordered oxycodone when the resident’s pain was documented at levels 7 or 8 on four separate occasions (1/21/2026 at 2:27 a.m., 1/25/2026 at 6:28 a.m., 1/26/2026 at 1:10 a.m., and 1/29/2026 at 3:10 a.m.). During interviews, the ADON confirmed that the physician’s order specified hydrocodone for pain levels 4–6 and oxycodone for pain levels 7–10, and acknowledged that the nurses should have administered oxycodone instead of hydrocodone on those dates. The DON also stated that nurses are expected to follow physician orders and that the resident’s pain could not be completely relieved because the orders were not followed. Review of facility policies on Pain Assessment and Management and Administering Medications showed that medications are to be implemented and administered as ordered, including required time frames.
Failure to Develop and Implement Person-Centered Care Plans for Oxygen Use and Fall Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for identified resident needs. For one resident admitted with diagnoses including orthopedic aftercare, unspecified COPD, and acute and chronic respiratory failure with hypoxia, the physician ordered continuous oxygen at two liters per minute via nasal cannula every shift. The resident’s H&P documented that the resident did not have capacity to understand and make decisions, while the MDS indicated intact cognitive skills for daily decisions and a need for supervision with hygiene, toileting, and showering. Despite these findings and the continuous oxygen order, staff interviews and record review confirmed there was no care plan addressing the resident’s noncompliance or refusal related to oxygen use. During an observation at the bedside, the resident was found asleep with the oxygen concentrator running at five liters per minute, but the nasal cannula was not connected and was hanging on a portable emergency light on the rolling table. The RN present verified that oxygen was running at five liters per minute and that the cannula was not in place. A CNA stated that if the cannula was not connected, the resident had removed it. The LVN and ADON both confirmed on review that there was no care plan developed for the resident’s refusal or removal of the oxygen cannula. The DON stated that without a care plan for the resident’s removal of the oxygen cannula, the facility would not be able to provide care and address the resident’s refusal, and that the resident could have hypoxia for not using oxygen. For a second resident admitted with left shoulder primary osteoarthritis, morbid obesity, and right knee pain, the H&P documented fluctuating capacity to understand and make decisions. The resident’s care plan for fall risk, initiated at admission, included an intervention to keep the bed in a low position with brakes locked. The MDS showed intact cognitive skills for daily decisions and a need for moderate assistance with toileting and lower body dressing, and a Fall Risk Observation/Assessment identified the resident as high risk for falls. However, during observation, the resident was found asleep with the bed in a high position. The ADON confirmed there was no care plan addressing the resident’s bed being kept in a high position, even though the resident was at high risk for falls and reportedly preferred the bed high. A CNA stated it was the first time she observed the bed high and acknowledged the resident could fall off if left too high, and an LVN stated he had just learned of the resident’s preference for a high bed and that a care plan should have been developed for this preference to prevent falls. The DON confirmed that the resident was high risk for falls, had no care plan for a high bed position, and that the resident put the bed up high and this should have been care planned as a resident preference.
Failure to Maintain Low Bed Position for High Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a high fall-risk resident’s environment was free from accident hazards and that care-planned fall-prevention interventions were implemented. The resident was admitted with diagnoses including left shoulder primary osteoarthritis, morbid obesity, and right knee pain, and had a history and physical noting fluctuating capacity to understand and make decisions. The resident’s care plan for fall risk, initiated shortly after admission, specified that the bed should be kept in a low position with brakes locked. A subsequent MDS assessment documented that the resident’s cognitive skills for daily decision-making were intact and that the resident required moderate assistance for toileting and lower body dressing. A Fall Risk Observation/Assessment identified the resident as being at high risk for falls. During an observation outside the resident’s room, surveyors found the resident asleep in bed with the bed in a high position, contrary to the care-planned intervention. In interviews and concurrent record reviews, the ADON confirmed there were no care plan interventions addressing the bed being in a high position and acknowledged that the resident could fall and be injured if the bed were high. CNA 1 reported it was the first time she observed the bed too high and stated the resident could fall off the bed if left in that position. The DON reviewed the Fall Risk Observation/Assessment and confirmed the resident was high risk for falls, that there was no care plan developed for use of a high bed position, and that the resident raised the bed and this preference had not been care planned. The facility’s Falls/Accident/Fall Management Prevention policy stated that, based on assessment, staff and the physician will identify pertinent interventions to prevent falls and address fall risks, but this was not followed in relation to the resident’s high bed position.
Failure to Follow Oxygen Orders and Ensure Proper Oxygen Administration
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards and physician orders for a resident with COPD and acute and chronic respiratory failure with hypoxia. The resident was admitted with diagnoses including unspecified COPD, orthopedic aftercare, and acute and chronic respiratory failure with hypoxia. An H&P dated 12/19/2025 documented that the resident did not have capacity to understand and make decisions, while an MDS dated 12/25/2025 indicated intact cognitive skills for daily decisions and a need for staff supervision with hygiene, toileting, and showering. Initial physician orders on 12/19/2025 directed oxygen at 4 L/min via nasal cannula, continuous with humidification for COPD and shortness of breath every shift, and a subsequent order dated 1/14/2026 changed the oxygen to 2 L/min via nasal cannula continuously every shift. On observation on 1/29/2026 at 9:19 a.m., the resident was found asleep at bedside with an oxygen concentrator running at 5 L/min via nasal cannula, but the nasal cannula was not connected to the resident and was instead hanging on a portable emergency light on top of the resident’s rolling table. A concurrent observation and interview with an RN confirmed that the oxygen was running at 5 L/min and that the nasal cannula was not attached to the resident. The RN called an LVN to obtain a pulse oximeter reading. At 9:25 a.m., the LVN placed the pulse oximeter on the resident’s left index finger, which showed an oxygen saturation of 92%, then reconnected the nasal cannula to the resident. The LVN stated that the resident’s oxygen saturation fluctuated between 80% and 90% while on 5 L/min, and the resident subsequently awoke, coughed up white phlegm, and the oxygen saturation increased to 91%. During interviews and record reviews, the ADON confirmed that the physician’s order dated 1/14/2026 specified oxygen at 2 L/min via nasal cannula and stated that a physician order was required to increase or titrate the oxygen, and there was no such order in place. The ADON stated that a resident not connected to ordered oxygen could experience shortness of breath. The LVN reported having observed the resident’s oxygen set at 5 L/min and acknowledged that the resident had a history of COPD and that giving high oxygen can cause shortness of breath. The DON stated that nurses should follow the physician’s order for continuous oxygen at only 2 L/min and that higher oxygen administration could result in hyperventilation. Review of facility policies showed that medications, including oxygen, must be administered in accordance with prescriber orders and that oxygen administration procedures require ensuring the proper flow of oxygen is being administered, which was not followed in this case.
Failure to Document Family Medication Concern in Resident Medical Record
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident by not documenting a family member’s report and related discussion about the resident’s medications. The resident was admitted with diagnoses including orthopedic aftercare, unspecified psychosis, and a history of falls. The admission History and Physical documented that the resident did not have capacity to understand and make decisions, while the subsequent MDS assessment indicated intact cognitive skills for daily decisions, a need for staff supervision with hygiene, toileting, and showering, and use of antipsychotic medication. On the second day after admission, the resident’s family member reported finding pills in a clear plastic bag and communicated this concern, including a photo, to the Social Service Assistant. The Social Service Assistant later confirmed that the family member had spoken with her about the resident’s medications and had shown her a picture of a clear plastic bag with pills, reporting that the resident had been caught with pills in the general acute care hospital. The Social Service Assistant acknowledged that she did not document this conversation or the concern in the resident’s medical record. Review of the facility’s Charting and Documentation policy showed that all changes in a resident’s medical, physical, functional, or psychosocial condition, as well as events or incidents involving the resident, must be documented in the medical record to facilitate communication among the interdisciplinary team. The DON stated that the Social Service Assistant should have documented the concerns and conversation with the family member and that the absence of this documentation rendered the resident’s medical record incomplete, contrary to facility policy.
Failure to Maintain Oxygen Tubing Off the Floor for Infection Control
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to the handling of oxygen tubing for one resident. The resident was admitted with diagnoses including orthopedic aftercare, unspecified COPD, and acute and chronic respiratory failure with hypoxia. The resident’s History and Physical dated 12/19/2025 indicated the resident did not have the capacity to understand and make decisions, while the MDS dated 12/25/2025 documented that the resident’s cognitive skills for daily decisions were intact and that the resident required supervision from staff for hygiene, toileting, and showering. During an observation at the resident’s bedside, the resident was asleep with an oxygen concentrator set at five liters per minute via nasal cannula. The nasal cannula was not connected to the resident and was hanging on a portable emergency light on top of the resident’s rolling table, with the oxygen tubing touching the floor. In interviews, the ADON stated that oxygen tubing should not be touching the floor for infection control, and the DON stated the resident could get an infection if oxygen tubing was touching the floor. The DON also stated that the facility did not have a specific written policy stating that oxygen tubing should not touch the floor, but that the facility’s practice was to keep oxygen tubing off the floor for infection control.
Failure to Maintain Effective Interior Pest Control Program
Penalty
Summary
The facility failed to maintain an on-going, effective pest control management program that monitored, identified, controlled, and prevented pest infestations throughout the building, including interior areas. One resident with DM II, depression, COPD, and fluctuating capacity, but assessed as cognitively intact and requiring maximal assistance with toileting and showers and total assistance with chair-to-bed transfers, reported seeing cockroaches in her room and in the hallway outside her room on multiple occasions over the prior several months. She stated she informed facility staff, who responded by killing the cockroaches by stepping on them and discarding them in the trash. Another cognitively intact resident with asthma, anxiety disorder, and muscle weakness, who required moderate assistance with toileting and transfers and was dependent for chair-to-bed transfers, reported seeing cockroaches in her room two to three weeks prior and expressed worry that the cockroaches would crawl onto her bed. Record review and staff and contractor interviews showed that the facility’s pest control program focused on monthly exterior inspections and treatments conducted by a pest control management company, while the interior of the facility was not included in routine monthly inspections. The Maintenance Supervisor confirmed that the pest control company only inspected the exterior monthly and that interior inspections were done only when specific pest issues were identified and reported, and further stated there was no documented record indicating that the facility’s interior was routinely inspected as part of the pest control program. The facility’s pest control policy, last revised on 11/6/2025, stated that the facility would maintain an effective, on-going pest control program to keep the building free of insects and rodents. The Maintenance Supervisor acknowledged that the lack of an on-going, effective pest control program, including routine interior inspections, had the potential for pest infestation that could lead to infection and illness among residents.
Incomplete Fall Risk Documentation for Dependent Resident With Paraplegia
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident by not correctly documenting the resident’s fall risk status on Fall Risk Observation/Assessment forms. The resident was admitted with diagnoses including paraplegia, osteoarthritis of the hip, and a stage 4 sacral pressure ulcer, and the H&P documented fluctuating capacity to understand and make decisions. An MDS assessment indicated the resident was dependent on staff for toileting hygiene, personal hygiene, showers, dressing, and transfers. Despite these conditions, the Fall Risk Observation/Assessment forms dated 10/20/2025 and 11/24/2025 indicated the resident did not have neuromuscular or functional health conditions and risk factors for falls such as loss of arm or leg movement. During a concurrent interview and record review, the DON confirmed that the Fall Risk Observation/Assessment form is one of the tools used to evaluate residents’ fall risk and provide necessary care and interventions, and that the form generates a score based on the answers provided. The DON stated that the resident’s Fall Risk Observation/Assessment forms were incomplete and did not indicate the diagnosis of paraplegia, which resulted in a lower fall risk score. The facility’s Charting and Documentation policy required that all services, progress toward care plan goals, and any changes in the resident’s condition be documented in an objective, complete, and accurate manner to facilitate communication among the interdisciplinary team, but this standard was not met for this resident’s fall risk documentation.
Failure to Accurately Document Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to accurately document the administration of apixaban, an anticoagulant, for a resident with diagnoses including sepsis, end stage renal disease, and diabetes mellitus type II. The resident was admitted with an order for apixaban to be given twice daily for deep vein thrombosis prophylaxis. On the morning in question, the LVN marked the medication as administered on the Medication Administration Record (MAR), despite the medication still being present in the bubble pack and not actually given to the resident. The LVN was unable to explain why the medication was documented as given when it had not been administered. Further review by facility leadership confirmed that the resident was out for dialysis at the time the medication was marked as given, and there was no nursing note explaining the discrepancy. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both acknowledged that the MAR should accurately reflect medication administration and that signing for a medication not given creates a discrepancy in the medical record. Facility policy requires all services and changes in condition to be documented completely and accurately to facilitate communication among the care team.
Failure to Maintain Resident Dignity and Communication Standards
Penalty
Summary
Staff failed to uphold resident dignity and respect by not addressing a resident by their preferred name and by using inappropriate terms of endearment. Specifically, a Licensed Vocational Nurse (LVN) was observed calling a resident "honey" on multiple occasions when the resident was requesting medication. The resident had an intact thought process and required moderate assistance with activities of daily living. The LVN acknowledged using the term and admitted that it was not appropriate unless it was care planned and the resident's preference. The Director of Nursing confirmed that staff should always address residents by their names as a matter of dignity, as outlined in the facility's policy. Additionally, several Certified Nursing Assistants (CNAs) and an Occupational Therapist were observed conversing in a dialect other than English in the hallways near resident rooms. The CNAs admitted that they should communicate in English in resident areas to ensure all residents feel included and respected, as not all residents understand their dialect. The Director of Nursing reiterated that staff are expected to speak English in resident areas, in accordance with the facility's communication courtesy policy.
Medication Storage and Self-Administration Assessment Deficiency
Penalty
Summary
A deficiency was identified when a bottle of nasal spray was found on a resident's bedside table without proper assessment for self-administration of medication. The resident, who had been admitted with diagnoses including diabetes mellitus and hypertension, was observed to have an intact thought process and required supervision for activities of daily living. The nasal spray had been brought in by the resident's daughters, and the resident reported using it that morning. Both a CNA and an LVN confirmed the presence of the nasal spray at the bedside, with the LVN stating she was unaware of the medication being there and acknowledging that medications should not be kept at the bedside due to the risk of access by other residents. Further review and interviews revealed that the facility's policy required an interdisciplinary team assessment before allowing residents to self-administer medications, and that such medications must be stored securely and not accessible to other residents. The Director of Nursing confirmed that the resident had not been assessed for self-administration and emphasized the importance of secure storage to prevent potential accidents. The failure to assess the resident and to store the medication securely constituted a breach of facility policy and created a situation where other residents could potentially access and misuse the medication.
Failure to Administer Ordered Antibiotic Upon Readmission
Penalty
Summary
A deficiency occurred when a resident was not administered an antibiotic, fluconazole, as ordered by the physician following readmission from a general acute care hospital. The resident, who had significant cognitive impairment and required total assistance with activities of daily living, was readmitted with diagnoses including attention to a gastrostomy and chronic obstructive pulmonary disease. The hospital discharge summary and subsequent physician order specified that fluconazole 200 mg should be given once daily for seven days, starting on the day of readmission. Upon review, it was found that the resident did not receive the first dose of fluconazole on the day of readmission. Nursing staff assumed the initial dose had been administered at the hospital, but there was no confirmation or communication from the hospital to verify this. The medication was available in the facility’s emergency kit, and both nursing staff and the DON acknowledged that the order should have been clarified and the medication administered within four hours of receipt, as per facility policy and standard practice. The failure to administer the antibiotic as ordered was attributed to miscommunication and lack of order clarification regarding whether the first dose had been given prior to transfer. The facility’s policies on medication reconciliation and physician orders emphasized the importance of timely administration and verification of medication history upon admission or readmission, but these procedures were not followed in this instance.
Nonfunctional Call Light in Resident Room
Penalty
Summary
A deficiency was identified when a resident's call light was found to be nonfunctional since their admission. The resident, who had a diagnosis of hypertension and a history of falls, required moderate assistance with activities of daily living and had an intact thought process. During an observation and interview, the resident demonstrated that their call light did not activate the visual indicator outside the room, and reported having to rely on their roommate's call light to request assistance. This issue was confirmed by a Licensed Vocational Nurse, who also observed that the call light did not work and acknowledged the importance of a functioning call system for timely response to resident needs. Further review of facility policy indicated that the resident call system is required to remain functional at all times and should be routinely maintained and tested by the maintenance department. The Director of Nursing confirmed the importance of a working call light system for communication between staff and residents, noting that a malfunction could result in staff being unable to meet residents' needs immediately. The deficiency was based on direct observation, resident and staff interviews, and review of facility records and policies.
Failure to Obtain HCAI Authorization for Portable AC Installation
Penalty
Summary
The facility failed to obtain written authorization or approval from the Department of Healthcare Access and Information (HCAI) prior to the use of a portable air-conditioning unit in a resident room. During observations, surveyors noted a portable AC unit operating with its ducting routed through a window, secured with duct tape. Interviews with maintenance staff confirmed that the portable AC was installed at a resident's request and that no permit from HCAI was obtained. The Maintenance Supervisor and Administrator both acknowledged that the HVAC unit was installed temporarily due to hot weather and that they were unaware of the requirement to contact HCAI for approval. The Administrator also stated that he was unfamiliar with HCAI and had not contacted the agency prior to installation. Additionally, the facility did not notify the Department of Licensing/Certification within five days of commencing the alteration, as required. Review of facility policies indicated that portable HVAC systems should only be used during power outages or extreme weather, and that maintenance personnel are to follow established safety regulations. There was no documented evidence that HCAI had approved the temporary use of the portable AC unit, and the facility's actions were not in accordance with state building code requirements for healthcare facilities.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards of practice by administering oxygen therapy without a physician's order. The resident, who had diagnoses including Parkinson's Disease, difficulty walking, and shortness of breath, was observed to have been on daily oxygen for several days following readmission from an acute care hospital. Review of the resident's records, including the admission record, history and physical, and physician orders, confirmed that there was no physician order for oxygen use during this period. The care plan referenced giving medications as ordered by the physician, but no specific order for oxygen was present. Multiple staff interviews confirmed that oxygen was administered to the resident without a physician's order, and staff acknowledged that such an order is required for oxygen therapy. The facility's policy and procedure also specified that medications and treatments, including oxygen, must be administered only upon a written physician order. The Director of Nursing confirmed that the nurses failed to obtain the necessary order and that oxygen is considered a medication requiring a physician's authorization before use.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was observed and documented by surveyors, indicating a lack of systematic measures to address infection risks within the facility. No specific residents or staff members were mentioned in relation to the deficiency, and no additional details about individual medical histories or conditions were provided in the report.
Failure to Supervise Nursing Students During Resident Transfer
Penalty
Summary
The facility failed to provide adequate supervision of nursing students during direct resident care, resulting in an incident where a student nurse, without facility staff present, assisted a resident to the floor during a transfer. The resident, who had end stage renal failure and hypertension and required moderate assistance with activities of daily living, experienced weakened knees during a transfer from chair to bed. The student nurse, unable to support the resident's weight, assisted the resident to a sitting position on the floor. No facility staff were present during this transfer, and the event was only reported to facility staff after the fact by the clinical instructor. Additionally, after being informed by the clinical instructor that the resident had been assisted to the floor, the facility failed to document and assess the resident following the incident. Interviews and record reviews confirmed that the facility's policy and the educational affiliation agreement required nursing students to be supervised by a facility representative during clinical hours, and that all resident care activities by students must be under the supervision of a licensed nurse. These requirements were not followed, leading to the deficiency.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident with multiple chronic conditions, including multiple sclerosis, COPD, and dementia. The deficiencies included not dating the resident's oxygen tubing and humidifier bottle when changed, not ensuring the humidifier bottle contained water while in use, and not providing a supplies bag for the oxygen tubing when not in use. Additionally, the resident was administered oxygen therapy without a physician's order, contrary to facility policy and standard practice. These issues were observed during interviews and record reviews, where staff confirmed the lack of proper documentation, missing supplies, and absence of a physician's order for oxygen therapy. The resident's care plan indicated a risk for respiratory complications and required adherence to infection control protocols and physician-ordered oxygen therapy. However, observations revealed that the oxygen cannula was not dated, the humidifier bottle was empty and not recently changed, and the supplies bag was missing. Both the LVN and DON acknowledged these deficiencies, confirming that the facility's policies were not followed regarding the dating, changing, and storage of respiratory equipment, as well as the requirement for a physician's order prior to administering oxygen therapy.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, an LVN documented a 72-hour change in condition (CIC) monitoring with an incorrect date, recording the monitoring before the actual CIC event occurred. Additionally, CNAs did not consistently document the resident's percentage of food intake for each meal, with several instances of missing entries for breakfast, lunch, or dinner. There were also inaccuracies in the documentation of the resident's bladder continence, with multiple shifts failing to record the required information. The resident involved had diagnoses including Guillain-Barre syndrome, age-related osteoporosis, and essential hypertension, and was noted to have intact cognition. During interviews and record reviews, both an RN and the DON confirmed that the documentation for bladder continence and nutritional intake was incomplete and inaccurate. The facility's own policy required objective observations and progress toward care plan goals to be documented, but these standards were not met in this case.
Call Light Not Accessible for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident, admitted with multiple sclerosis, COPD, and dementia, was found to have their call light on the floor and out of reach. The resident's care plan, which addressed their high risk for falls and injury, specifically required that the call light be placed within reach and that the resident be instructed to use it when needing assistance. The Minimum Data Set indicated the resident had moderately impaired cognition and required maximal assistance for several activities of daily living. The Fall Risk Assessment further confirmed the resident was at high risk for falls. During an observation, a Licensed Vocational Nurse confirmed that the call light was not within the resident's reach and acknowledged that this was necessary for resident safety. The Director of Nursing also stated that the call light should have been accessible and that its absence could delay care. The facility's policy required that each resident have a means to call staff for assistance from their bed, but this was not followed in this instance.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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