Sunset Villa Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 3232 E. Artesia Blvd., Long Beach, California 90805
- CMS Provider Number
- 555375
- Inspections on file
- 68
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Sunset Villa Post Acute during CMS and state inspections, most recent first.
A contracted activity provider was allowed to videotape multiple cognitively impaired residents during group activities and post identifiable videos on social media without resident or representative consent, while using mocking and crude language about their age, incontinence, cognitive decline, and physical limitations. Several residents with dementia, psychosis, metabolic encephalopathy, and anoxic brain damage, many lacking decision-making capacity, were visibly recorded dancing or sitting in wheelchairs during these sessions. Facility staff, including activity staff, were present during the events, did not stop the videotaping or inappropriate remarks, and some were reported to be recording as well. Later interviews with residents and staff confirmed that consent was not obtained and that such videotaping was contrary to facility policy on confidentiality, dignity, and social media use.
The facility failed to follow manufacturer instructions for diclofenac gel for two residents by having nurses squeeze the medication into a cup instead of using the dosing card, despite orders for specific gram amounts and unused dosing cards remaining in the cartons. The DON and ADON stated the dosing card must be used to measure the ordered dose. The facility also failed to follow controlled drug shift-change accountability procedures when an LPN signed count and narcotic forms before the incoming nurse was present, and staff did not perform the Cubex blind count process described in policy.
Dietary staff were observed in the kitchen with hair nets that did not fully cover the head, and the ice machine had brown and pink discoloration on the upper interior surface. In another observation, a CK prepared sandwiches, touched a refrigerator handle, and continued food prep without changing gloves or performing hand hygiene. The DS stated the ice was used for all residents and staff and that gloves and hand hygiene should have been changed after touching a non-food contact surface.
Failure to document COVID-19 vaccination education and status for 32 of 32 licensed practitioners. The IPN reviewed the COVID-19 staff vaccination binders and stated there was no documented evidence that education on the benefits and side effects of the vaccine had been provided. The IPN also stated licensed practitioners’ vaccination status should be obtained because they have direct access to residents. The DON stated all staff need to be educated and offered the current COVID-19 vaccine, and the facility policy required education on the vaccine’s benefits, risks, and potential side effects for staff.
Failure to Protect Resident Dignity and Provide Scheduled Showers: One resident was observed walking in the hallway with the back of his gown open, exposing his back and brief in view of staff. Another resident, who had mild cognitive impairment and needed substantial ADL assistance, reported difficulty getting showers despite a set shower schedule; record review showed repeated bed baths on scheduled shower days instead of showers, and the DON confirmed a bed bath is not the same as a shower.
Failure to reassess continued use of a sensor pad alarm for a resident with impaired cognition, anoxic brain damage, and high fall risk. The resident had bed and wheelchair alarms in place to alert staff when he tried to get up unassisted, but the initial restraint evaluation did not document alternatives tried before use. Staff stated the alarm was loud enough to be heard throughout the nursing station and could startle or upset the resident, and the DON leadership acknowledged only a single observation was used without further evaluation of the alarm’s psychological or restrictive effect.
A resident with bipolar disorder, schizophrenia, and anxiety had a Lexapro order that listed depression with tearfulness, while the psychiatry note documented use for generalized anxiety disorder. The ADON and DON confirmed the diagnosis list did not show anxiety and stated the order indication should match the psychiatrist’s plan; the facility policy described adequate indication for psychotropic use but did not include procedures for clarifying psychotropic orders.
Inaccurate MDS Medication and Diagnosis Coding: The facility failed to accurately code the MDS for two residents. One resident’s MDS did not reflect use of Buspirone for anxiety despite the order summary showing the anti-anxiety medication, and another resident’s MDS listed anticoagulant use but did not include atrial fibrillation as an active diagnosis even though the order summary showed Eliquis for that condition. The MDSN stated the assessments should have matched the residents’ medications, diagnoses, and care needs.
PASARR level 1 resident review screenings were not appropriately resubmitted for two residents when mental health diagnoses and medications changed. One resident had bipolar disorder, anxiety disorder, schizophrenia, and later an order for Lexapro for depression, but no new PASARR screening was submitted after the new medication. Another resident had dementia, bipolar disorder, depressive disorder, and anxiety disorder, but the PASARR screening did not include all of the mental health diagnoses noted in the record. The DON and ADON stated the screenings should have reflected the updated diagnoses and treatment needs.
A resident receiving Buspirone for anxiety had a care plan that listed the medication but lacked person-centered interventions and monitoring for effectiveness, despite cognitive impairment and dependence for many ADLs. Another resident with ESRD and dialysis dependence had no care plan for an AV shunt. The DON and MDSN acknowledged the care plans were not individualized as required by policy.
Resident Ate Another Resident’s Food Without Adequate Supervision: A resident with impaired cognition, dysphagia, and limited decision-making ability was observed eating a sandwich from another resident’s labeled food container. An LVN confirmed the food belonged to the other resident, stated it may have been contaminated, and noted the resident could choke because the food was not ordered for him. The LVN also confirmed there was no care plan addressing the resident’s behavior of taking other residents’ food.
Failure to Provide and Document Catheter Care and Monitoring: Three residents with indwelling catheters did not have documented catheter care, urine assessment, or urine output monitoring as required. Two residents with indwelling catheters had no documented care or infection monitoring, and one resident with a suprapubic catheter lacked a physician order for the catheter and had no monitoring in place for UTI or catheter-related issues. The DON and MDSN confirmed the missing orders and documentation, and the facility policy required routine hygiene, urine observation, and documentation of catheter care.
Staff failed to follow dialysis access precautions for three residents with ESRD and HD dependence. Blood pressures were taken on arms with AV shunts despite orders not to use those extremities, one resident missed scheduled HD without the documented COC actions noted by the DON and ADON, and another resident’s right-arm AV access was not properly assessed or documented while BP readings were still obtained on that arm.
An expired fluticasone furoate Ellipta inhaler was found in a med cart and was given to a resident after the beyond-use date. The resident had asthma, COPD, interstitial pulmonary disease, and acute respiratory failure with hypoxia, and the DON confirmed the inhaler was first opened, later expired, and was documented as administered twice after expiration. The LVN and ADON both acknowledged the inhaler had expired.
Failure to Follow Up on Recommended Thyroid Ultrasound: A resident with a right thyroid nodule had repeated PM&R notes stating that an US was recommended and would be scheduled, but the facility did not follow up to confirm completion of the diagnostic testing. The ADON stated the notes should have been clarified with the MD, and the DON stated that without follow-up the facility could not provide the right treatment and interventions for the resident.
Failure to provide ordered RNA services for a resident with cervical myelopathy, bone density disorder, and bilateral hand OA. The resident was cognitively intact but dependent for transfers, lower-body dressing, and personal hygiene. The order summary included ROM to both LEs, an abductor wedge, and a right resting hand splint, but the DSD confirmed missing documentation for several scheduled treatments and stated that if it was not documented, it was not done.
A resident with severely impaired cognition and documented lack of decision-making capacity had a binding arbitration agreement signed in the resident’s name. The AD and AA stated the agreement was explained and the resident nodded, but they did not verify capacity or confirm informed decision-making with nursing staff, and the facility policy required verbal acknowledgment from the resident or representative before signing.
QAPI Committee Failed to Address Systemic Care Planning, PASARR, and MDS Deficiencies. The facility's QAPI Committee did not identify or implement corrective action for systemic issues affecting all 173 residents, including failure to initiate and implement person-centered care plans for every resident, failure to complete PASARR in a timely manner, and failure to ensure MDS assessments were accurate to residents' needs and services. The ADM stated these issues were not identified by QAPI and acknowledged the facility had not completed QAPI for the prior survey deficiencies.
Failure to follow infection control practices for staff vaccination, PPE use, and respiratory equipment. The facility did not document annual flu vaccine status, education, or offering of the current flu vaccine for all licensed practitioners. An LVN did not wear PPE while handling a resident’s G-tube and another resident’s foley catheter, despite EBP requirements for residents with indwelling devices. The facility also did not change a resident’s nebulizer tubing weekly, and the tubing remained in use beyond the labeled date.
A resident with cerebrovascular disease, seizures, and on Eliquis via G-tube, care planned for bleeding risk, experienced a change in condition when they began coughing up blood. An SBAR and nurse’s note documented coughing blood and elevated BP, and a physician ordered transfer with a private BLS ambulance called. Later notes described increased bleeding, clenched jaw, and need for continuous oral suctioning, with EMS and ED records showing uncontrolled oral bleeding, large-volume suctioned blood, and markedly elevated BP. However, the facility’s vitals summary showed no documented monitoring or vital signs at the time the resident was first noted to be coughing blood, despite facility policy requiring documentation of all information related to changes in condition, resulting in incomplete medical records.
A resident with severe cognitive impairment and a history of falls was not adequately supervised while seated in a wheelchair, despite a care plan requiring close observation. Staff failed to provide timely redirection and cueing, and the resident was able to stand up unassisted and fell before staff could intervene, resulting in injury and transfer for further evaluation.
A resident with diabetes and renal failure did not receive a timely podiatry consultation as ordered due to insurance denials and transition to new coverage. Although the referral was approved, podiatry services were not provided and private-pay options were not offered while awaiting authorization, contrary to facility policy requiring assistance in obtaining necessary health services.
A resident with diabetes and hyperlipidemia, requiring a therapeutic diet, was repeatedly served white bread and pasta despite documented preferences for wheat bread and no pasta. The resident reported frustration over dietary staff not honoring these requests, and the Dietary Supervisor confirmed the error, noting that staff are responsible for checking menu cards to ensure preferences are met.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A resident with multiple diagnoses, including encephalopathy and depression, was prescribed Seroquel for psychosis-related behaviors, but the MDS assessment did not reflect the use of this antipsychotic medication. Both the MDSD and DON confirmed the inaccuracy, which resulted in the resident's care plan not accurately reflecting their medication regimen.
A resident with a history of falls, severe cognitive impairment, and total dependence for ADLs was not provided with a revised care plan to include non-skid socks, as recommended by the IDT after an unwitnessed fall. The intervention was not added to the care plan, despite facility policy requiring updates after significant changes or team recommendations.
A resident with a midline catheter and severe cognitive impairment did not receive Enhanced Barrier Precautions (EBP) during high-contact care activities, such as toileting, due to staff not using required PPE and lack of proper signage. Facility staff were unaware of the resident's EBP status, leading to a lapse in infection control measures as outlined in the care plan and facility policy.
The facility did not ensure that two residents with severe cognitive impairment had their advance directive (AD) preferences properly documented or that their representatives were given the opportunity to formulate an AD, as required by facility policy. In both cases, the necessary signatures and clear documentation were missing, and responsible parties were not adequately involved or informed.
A resident with a diagnosis of unspecified psychosis and moderate cognitive impairment did not receive a psychiatry consultation as recommended by the PASARR assessment. The care plan and medical orders lacked documentation of the required specialized services, and staff confirmed that the PASARR recommendations were not followed.
A resident with multiple mental health diagnoses was admitted and readmitted to the facility, triggering a positive PASRR Level 1 screening that required a Level 2 evaluation. After the state closed the case due to the resident's inability to participate in the evaluation, facility staff did not resubmit a new Level 1 screening as required by policy, resulting in the resident not receiving the mandated PASRR Level 2 assessment.
Multiple residents did not have comprehensive, individualized care plans or had care plan interventions that were not implemented, including lack of monitoring for seizure medication side effects, missing documentation and care planning for safety devices like bed alarms and bolsters, and failure to follow fall prevention protocols. Staff interviews and record reviews confirmed these deficiencies, which were not in accordance with facility policy.
The facility did not document Emergency kit (E-Kit) usage on the required log and failed to receive or review daily activity and discrepancy reports from the Cubex medication dispensing system for several months. An LVN confirmed that E-Kit usage was not properly logged, and the DON stated that Cubex reports had not been received or reviewed since a change in leadership, contrary to facility policy.
Two residents did not receive appropriate dental care and follow-up, including lack of communication and documentation regarding denture requests and dental service recommendations. One resident with cognitive impairment and swallowing difficulties was not updated about her partial denture status, while another with chronic health conditions did not receive assistance in obtaining a new upper partial denture after expressing dissatisfaction with her current one. Staff interviews and record reviews confirmed that required follow-up and documentation were not completed.
A resident with severe cognitive impairment and multiple serious medical conditions was found in bed with her call light on the floor and out of reach. Staff interviews and facility policy confirmed that call lights should be accessible, especially for high fall risk residents, but this was not ensured in this case.
A resident with dementia and a history of falls was placed on a bed alarm without proper assessment, physician order, or documentation. The alarm, which restricted the resident's movement and caused discomfort, was not included in the care plan or monitored as required. Staff and nursing leadership were unaware of the alarm's use, and facility policy regarding restraints was not followed.
A resident with a diagnosis of psychosis and an order for Olanzapine was not accurately identified as having a psychotic disorder on the MDS assessment. The MDS Coordinator acknowledged the omission, and facility policy requires complete and accurate documentation.
A resident with major depressive disorder and moderate cognitive impairment did not receive a required quarterly Interdisciplinary Team (IDT) meeting. The resident was unaware of her care plan and not informed about her discharge, and records confirmed the missed IDT meeting. Facility policy and staff interviews indicated that these meetings are essential for updating care plans and addressing resident concerns.
A resident with a gastrostomy and history of aspiration was observed lying flat in bed while receiving tube feeding, despite care plan and facility policy requiring the head of bed to be elevated at least 30 degrees. An LVN corrected the position upon entering the room, and staff interviews confirmed the importance of this intervention to prevent complications.
A resident who was dependent on staff for all ADLs, including personal hygiene, was observed with unkempt fingernails emitting a fecal matter odor and containing a black substance. Interviews with a CNA and the DON confirmed that nail care is part of routine hygiene and is necessary to prevent infection and injury. Facility policy requires daily cleaning and regular trimming of nails, but this was not provided, resulting in a deficiency in grooming and hygiene care.
A resident with a history of falls and significant mobility limitations did not have bilateral bed bolsters in place as care planned and recommended by the IDT after readmission from the hospital. The omission occurred because the order for the bolsters was not reentered, and staff confirmed the intervention was not implemented, leaving the resident without the required fall prevention measure.
Surveyors found that food items were not properly labeled, dated, or sealed, and expired products were not discarded as required. Freezer temperatures were not consistently documented, and sanitizer concentration was below policy standards. Additionally, a dietary aide wore an uncovered wristwatch while handling food, in violation of the facility's dress code and infection control policies.
A QAN did not perform hand hygiene after touching the lunch tray cart and before handling additional trays and food items, resulting in a breach of infection control protocols. Facility policy and staff interviews confirmed that hand hygiene is required between tasks and after contact with high-touch surfaces to prevent cross-contamination.
A resident with a history of stroke and sepsis was prescribed doxycycline for sepsis, but the infection did not meet Loeb's or McGeer's Criteria for antibiotic use. The IPN identified that the criteria were not met and confirmed that the physician was not notified, as required by facility policy. The DON also acknowledged that the physician should have been informed. This resulted in a deficiency related to the facility's failure to follow its antibiotic stewardship program.
The facility did not maintain complete and accessible documentation of COVID-19 vaccination status for all staff, including employees, practitioners, and contracted personnel, as required by policy. Interviews revealed that the IPN had not finished auditing vaccination records and lacked information for certain staff and consultants, resulting in incomplete tracking of vaccination status.
The facility failed to honor residents' rights to choose their attending physician by not confirming with the original PCP about his departure and not providing written notification of the change to five residents. This led to residents being informed of a physician change without their consent, disrupting continuity of care. The facility did not adhere to its policy requiring written notification of any changes in attending physician.
A resident with a history of falls experienced an unwitnessed fall and was left in extreme pain for over two hours due to the failure of an LVN to report the incident to the physician and conduct a proper assessment. The resident was later found to have a hip fracture and required surgery. The lack of communication and adherence to facility policies contributed to the delay in pain management.
A resident with a history of falls was found on the floor in pain, but the LVN failed to notify the physician and family, delaying care. The resident was later discovered by the RP in severe pain, leading to emergency services being called. The facility's policy required notification of significant changes, which was not followed.
A resident with a history of falls experienced an unwitnessed fall, and the LVN failed to assess or report the incident properly. The resident was found in pain, but the LVN did not notify the physician or RNS, nor did they inform the resident's RP. The resident's pain was only addressed after the RP's intervention, highlighting a lack of competency in fall assessment and reporting procedures.
A resident with dementia was transferred to another facility without notifying their representative, violating the resident's right to informed decision-making. Facility staff confirmed the lack of documentation for the notification, which was required by the facility's policy.
A resident experienced significant weight loss due to the facility's failure to identify and report decreased oral intake to the physician in a timely manner. Despite recommendations from the Registered Dietician and the resident's care plan, staff did not monitor the resident's weight and oral intake adequately, leading to severe weight loss and the need for a gastrostomy tube. The facility did not adhere to its policies, resulting in a lack of timely interventions.
Failure to Monitor Contracted Activity Provider Leading to Unauthorized Videotaping and Disparaging Social Media Posts
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ privacy, confidentiality, and dignity by not monitoring a contracted activity provider who videotaped residents and posted the videos on social media without consent, while making disparaging remarks about them. Six residents with varying levels of cognitive impairment were identified in the videos. These residents had diagnoses including metabolic encephalopathy, dementia, psychosis, bipolar disorder, depression, and anoxic brain damage, and most were documented as unable to make consistent and reasonable decisions or lacking capacity for medical decision-making. One resident was documented as able to make reasonable and consistent decisions, but there is no indication that she or any responsible party gave permission to be videotaped. Surveyors reviewed multiple Instagram and TikTok videos showing the contracted activity provider conducting group activities in the presence of identified residents and other, unidentified residents. In these videos, the provider rapped and spoke using language that mocked and belittled residents, including references to residents’ incontinence, diapers, cognitive decline, arthritis, missing fingers, gray hair, and impending death, as well as sexually suggestive and crude phrases. The provider also referred to residents collectively as “Gramps” and compared elderly residents to children, emphasizing shared use of diapers and loss of teeth. In one video, the provider laughed when a male resident made a sexually explicit comment to a female resident and did not redirect or stop the interaction. The videos clearly showed residents’ faces and activities, and were posted publicly on social media platforms. The report documents that facility staff were present during several of these recorded activities and did not intervene to stop the videotaping or the disparaging content. Activity Assistants were visible in at least one TikTok video, and residents later reported that staff were taking videos during the performances. Interviews with residents confirmed that they were videotaped while dancing or participating in activities and that no one asked their permission. Facility staff, including the Restorative Nurse Assistant, Activity Director, Director of Staff Development, Director of Nursing, and Administrator, acknowledged during interviews that videotaping residents without consent was not allowed, that staff should have monitored the contracted provider, and that staff present should have stopped the unauthorized recording and protected residents’ privacy. Review of facility policies on confidentiality, dignity, and social media use showed that the facility had written expectations to safeguard residents’ confidentiality, personal privacy, and dignity, and to use social media only within legal and ethical boundaries, but these were not followed in practice during the contracted activity sessions.
Diclofenac Dosing and Controlled Medication Accountability Failures
Penalty
Summary
The facility failed to ensure that manufacturer instructions were followed when administering diclofenac sodium topical gel to two residents. Resident 24 was admitted with diagnoses including osteoarthritis, psoriatic arthritis mutilans, prurigo nodularis, and acne keloid, and the record showed the resident lacked capacity to understand and make decisions. The resident’s orders included diclofenac gel for breast pain, joint pain, and chest keloid pain. During medication pass observation, an LVN squeezed the gel directly into a medication cup and applied the full amount to the resident’s chest instead of using the manufacturer’s dosing card. The unused dosing card remained glued inside the carton. The LVN stated the resident reported itching from the gel and that the gel was not being measured with the dosing card. The ADON stated the dosing card must be used and that estimating the dose in a cup was not acceptable. Resident 123 was admitted with osteoarthritis, bilateral shoulder pain, neuropathy, and pain related to nervous system prosthetic devices and implants. The resident’s history and physical indicated the resident lacked capacity for medical decision making due to chronic encephalopathy from CVA, and the MDS showed moderate cognitive impairment. The resident had an order for diclofenac sodium external gel 1% to both shoulders twice daily at 2 gm. During medication cart review and interview, an LVN stated she squeezed the gel into a medication cup and applied whatever amount was in the cup to both shoulders. She stated she did not use the dosing card and did not know it was inside the packaging. The dosing card was still taped inside the carton unused. The LVN stated accurate dosing was important to avoid side effects and to ensure effectiveness, and the DON stated nurses must use the dosing card to measure the ordered amount. The facility also failed to follow controlled medication accountability procedures on Station 3. An LVN signed the shift change Controlled Drugs Count Record and Narcotic Accountability forms ahead of time, before the end of the shift and without the incoming nurse present. The LVN stated she should have waited and signed together with the incoming nurse. The DON stated both nurses must endorse the forms together and review the medication cart and controlled medications together before the incoming nurse assumes responsibility. In addition, the facility did not follow its Cubex blind count procedure. During inspection, staff demonstrated that the Cubex displayed the available quantity before removal of medication, and the DON stated there was no blind count in practice. The facility’s Cubex policy stated that prior to removing a medication, the user enters the inventory count and discrepancies are logged if the counts do not match.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
Dietary staff were observed working in the kitchen without wearing hair restraints appropriately. During a concurrent observation and interview with the Dietary Supervisor, [NAME] 1's hair net did not cover the sides of the head, CK 2's hair net did not cover the sides and back of the head, Dietary Aid 1's hair net did not cover the sides and back of the head, and Dietary Aid 2's hair net did not cover the sides of the head. The facility's Dress Code policy stated staff should wear a hair net for hair, and if hair is long it should cover the ears or longer. The ice machine in the kitchen was observed with brown and pink discoloration on the upper interior surface. The Dietary Supervisor identified the substance as dirt and stated the ice produced by the machine was used for all residents and staff upon request. In a separate observation, CK 1 prepared sandwiches while wearing gloves, touched the refrigerator handle, opened the refrigerator, retrieved margarine, and then continued preparing the sandwiches without changing gloves or performing hand hygiene. The Dietary Supervisor stated gloves should be changed and hand hygiene performed after touching non-food contact surfaces. The facility's Sanitation, Hand Washing Procedure, and Food Handling policies stated ice used with food or drink shall be from sanitary sources, hands should be washed before and after handling foods, and food should be prepared and served in a safe and sanitary manner with hand hygiene and glove changes during food preparation.
Failure to Document COVID-19 Vaccination Education and Status for Licensed Practitioners
Penalty
Summary
The facility failed to provide documented evidence of COVID-19 vaccination status and education on the benefits and potential side effects of the 2025 to 2026 COVID-19 vaccine for 32 out of 32 licensed practitioners. During a concurrent interview and record review with the Infection Prevention Nurse, the facility’s binders for COVID-19 Staff Vaccination Status were reviewed, and the IPN stated there was no documented evidence that education on benefits and side effects had been provided. The IPN also stated that COVID-19 vaccination status for licensed practitioners should be obtained because they have direct access to residents. During an interview with the DON, the DON stated all staff need to be educated and offered the current COVID-19 vaccine because vaccines minimize sickness and protect residents in the facility. The facility’s policy titled Coronavirus Disease (COVID-19) - Vaccination of Staff, revised 1/2026, stated staff are educated about the benefits, risks, and potential side effects of the COVID-19 vaccine and defined staff as individuals who provide care, treatment, or other services for the facility and/or its residents, regardless of clinical responsibility or resident contact.
Failure to Protect Resident Dignity and Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure Resident 29 was treated with dignity when he was observed walking in front of Nursing Station 3 with the back of his gown open, exposing his back and adult brief. Multiple staff in and around the nursing station observed the exposure. Resident 29 had diagnoses including encephalopathy, generalized muscle weakness, and cognitive communication deficit, and records showed fluctuating capacity to make medical decisions and mild cognitive impairment. His MDS indicated he required supervision for all ADLs and used a walker and wheelchair. The facility also failed to ensure Resident 76 received scheduled showers. Resident 76 had diagnoses including a history of healed traumatic fracture, osteoarthritis of the left knee, and abnormalities of gait and mobility. Her H&P indicated she had the capacity to understand and make decisions, and her MDS showed mild cognitive impairment and substantial assistance needs for bathing and multiple other ADLs. Her care preferences indicated it was very important for her to be able to choose between a tub bath, shower, bed bath, or sponge bath, and the shower schedule showed showers were planned for Mondays and Thursdays during the 3:00 p.m. to 11:00 p.m. shift. Resident 76 stated she had a hard time getting showers and reported that her last shower had been on 3/30/2026 even though 4/6/2026 was her shower day. Record review showed repeated bed baths on scheduled shower days, including 3/2/2026, 3/9/2026, 3/12/2026, 3/23/2026, 3/26/2026, and 4/2/2026. CNA 6 stated Resident 76 was scheduled for showers on Monday and Thursday, that showers were the resident's right, and that the record did not show a refusal on 3/9/2026. The DON stated showers are important for body hygiene and that a bed bath is not the same as a shower.
Failure to Reassess Continued Use of Sensor Pad Alarm
Penalty
Summary
The facility failed to ensure ongoing assessment and evaluation for the continued use of a sensor pad alarm for one resident. Resident 142 was admitted on 11/7/2024 and later readmitted with diagnoses including anoxic brain damage, cognitive communication deficit, and abnormalities of gait and mobility. The resident’s H&P dated 12/9/2025 indicated the resident did not have the ability to understand and make decisions, and the MDS dated 2/3/2026 showed moderately impaired cognition and need for assistance with multiple activities of daily living. The resident’s order summary dated 4/6/2026 indicated that starting 1/8/2026 the resident may have a sensor pad alarm in bed and wheelchair to alert staff when the resident tried to get up unassisted. Fall risk assessments dated 12/21/2025, 1/4/2026, and 2/3/2026 identified the resident as high risk for falls. The restraint physical initial evaluation dated 1/4/2026 stated the facility placed the sensor pad alarm to alert staff when the resident tried to get up unassisted, but it did not indicate alternatives attempted to reduce risk of harm prior to application of the alarm. During observation on 4/6/2026, a sensor pad alarm with a blue light was observed under the resident’s mattress and another alarm was observed in the wheelchair. CNA 7 stated the resident needed the alarm because he was at high risk for falls and got out of bed without requesting assistance to go to the restroom. CNA 8 stated the alarm was loud enough to be heard anywhere in the nursing station and could startle or upset the resident. RNS 2 stated the facility should evaluate more than once to assess the psychological effect of a bed alarm and determine whether it limits the resident’s free movement, and the ADON stated the determination was based on a single observation with no further evaluation of psychological impact or restrictive effect over time.
Incorrect Lexapro Indication for Psychotropic Medication
Penalty
Summary
The facility failed to ensure one sampled resident was free of unnecessary psychotropic medication use when the Lexapro order did not match the psychiatrist’s documented indication. Resident 14 was admitted with diagnoses including bipolar disorder and anxiety disorder, had intact cognition, and the history and physical indicated the resident had capacity to understand and make decisions. The MDS showed active diagnoses of bipolar disorder and schizophrenia and indicated the resident was receiving antipsychotic and antidepressant medications, but it did not show an active diagnosis of depression. The order summary report listed Lexapro 5 mg daily for depression manifested by episodes of tearfulness, while the psychiatry follow-up note documented a plan to start Lexapro 5 mg in the morning for generalized anxiety disorder manifested by inability to relax. During interviews, the ADON and DON stated the diagnosis list did not indicate anxiety and that nurses should clarify the correct indication with the psychiatrist. The facility policy on psychotropic medication use described adequate indication as a documented clinical rationale based on assessment and therapeutic goals, but it did not include procedures for clarifying psychotropic medication orders.
Inaccurate MDS Medication and Diagnosis Coding
Penalty
Summary
The facility failed to provide accurate information in the MDS for two sampled residents. For Resident 17, the admission record listed diagnoses including DM, anxiety disorder, and dementia. The H&P dated 9/2/2025 stated the resident had fluctuating capacity to understand and make decisions, and the MDS described the resident as moderately impaired in cognitive functioning for daily decision making and needing supervision to maximal assistance with self-care tasks such as eating, hygiene, and dressing. However, the MDS indicated the resident was not taking an anti-anxiety medication. A review of Resident 17’s Order Summary Report dated 10/22/2025 showed Buspirone 15 mg by mouth three times a day for anxiety manifested by verbalizing feeling anxious. During interview and record review with the MDSN, the MDS and Order Summary Report were compared, and the MDSN stated the assessment should have coded that Resident 17 was taking an anti-anxiety medication. The MDSN stated the MDS should accurately reflect the medications the resident is taking and the treatments and services being provided. For Resident 40, the admission record listed diagnoses including DM, atrial fibrillation, and dementia. The MDS described the resident as moderately impaired in cognitive functioning for daily decision making and needing supervision assistance with self-care abilities such as eating and hygiene. The MDS indicated the resident was taking an anticoagulant, but did not list an active diagnosis for the anticoagulant. The Order Summary Report dated 7/9/2023 showed Eliquis 2.5 mg twice a day for atrial fibrillation. During interview, the MDSN stated the MDS should have included atrial fibrillation because the assessment showed what the resident has and the care staff are providing, and stated the diagnosis should have been on the list of active diagnoses.
PASARR screenings not updated for new mental health diagnoses and medications
Penalty
Summary
The facility failed to ensure PASARR level 1 resident review screenings were appropriately resubmitted for two residents when their mental health diagnoses and medications changed. Resident 14 was admitted with diagnoses including bipolar disorder and anxiety disorder, and later had a history and physical showing capacity to understand and make decisions, an MDS showing intact cognition, active diagnoses of bipolar disorder and schizophrenia, and use of antipsychotic and antidepressant medications. An order summary also showed Lexapro was ordered for depression manifested by episodes of tearfulness. During record review and interview, the ADON stated Resident 14’s PASARR level 1 screening dated 3/24/2025 identified paranoid schizophrenia, bipolar disorder, and anxiety disorder, but no additional PASARR screening was submitted after the resident started Lexapro for depression. The ADON stated another PASARR level 1 screening should have been submitted when the resident had a new diagnosis or was prescribed a new medication for a mental illness diagnosis so the resident could be evaluated and provided the appropriate treatment plan. Resident 19 was admitted with diagnoses including dementia, bipolar disorder, depressive disorder, and anxiety disorder. The H&P stated Resident 19 did not have the capacity to understand and make decisions, and the MDS showed severe cognitive impairment with dependence or extensive assistance for multiple activities of daily living and active diagnoses of anxiety disorder, depression, and bipolar disorder. The ADON reviewed Resident 19’s PASARR level 1 screening and stated it identified bipolar disorder and dementia, but did not include depressive disorder, mood disorder, or anxiety disorder; the ADON stated those diagnoses should have been included to ensure the facility was able to provide the services the resident needed.
Person-Centered Care Plans Not Implemented for Anxiety Medication and AV Shunt
Penalty
Summary
The facility failed to ensure a person-centered care plan was implemented for a resident receiving Buspirone for anxiety. The resident had diagnoses including diabetes mellitus, anxiety disorder, and dementia, with fluctuating capacity to understand and make decisions, moderate cognitive impairment for daily decision making, and dependence on staff for many self-care and mobility tasks. The resident’s care plan, dated 8/8/2025, identified a focus on anti-anxiety medication related to anxiety disorder manifested by verbalizing feeling anxious, with a goal that medication use would maintain functional status and an intervention to administer the medication as ordered. The care plan did not include other interventions to monitor or maintain the effectiveness of the medication, and no person-centered interventions were in place. During interview and record review, the MDS Nurse stated there was no person-centered care plan interventions for the anti-anxiety medication and that the interventions were not person centered and did not include monitoring of the resident’s behaviors or the effectiveness of the medication for the targeted behaviors. The DON stated that a care plan should be individualized to each resident’s needs, treatment, and services. The facility also failed to have a care plan for another resident’s AV shunt. That resident had ESRD and dependence on renal dialysis, with severely impaired cognition and extensive assistance needs for eating, oral hygiene, toileting hygiene, showering, and personal hygiene. During interview and record review, the LVN stated there was no care plan for the AV shunt and that it should be included because a care plan reflects the care provided to the resident. The DON stated care plans need to be individualized to meet resident needs, and the facility policy required a comprehensive, person-centered care plan with measurable objectives and timetables for each resident.
Resident Ate Another Resident’s Food Without Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent one sampled resident from accessing and consuming food intended for another resident. Resident 27 was admitted with diagnoses including metabolic encephalopathy, dysphagia, and respiratory failure. The resident's H&P dated 3/13/2026 stated that Resident 27 did not have the ability for medical decision making, and the MDS dated 3/17/2026 indicated moderately impaired cognition. The MDS also showed Resident 27 required moderate assistance with eating and was dependent for toileting hygiene, showering, and personal hygiene. During an observation on 4/6/2026 at 2:46 p.m., Resident 27 was seen sitting on the bed and eating a sandwich from a food container labeled for Resident 25. In a concurrent observation and interview, LVN 10 confirmed the food was intended for Resident 25 and stated it had already been distributed to that resident and may have been contaminated. LVN 10 also stated Resident 27 could choke when consuming food not ordered for him. During a concurrent interview and record review, LVN 10 confirmed Resident 27's diet order was soft and bite-sized, while Resident 25's diet order was regular, and stated there was no care plan in place to address Resident 27's behavior of taking other residents' food.
Failure to Provide and Document Catheter Care and Monitoring
Penalty
Summary
Proper catheter management was not provided for three sampled residents with indwelling catheters. For Resident 10, the record showed an indwelling urinary catheter for obstructive uropathy, and for Resident 184, the record showed an indwelling urinary catheter for neurogenic bladder. During concurrent review with the Infection Prevention Nurse, there was no documentation that urinary catheter care had been provided for either resident, and there was no documented monitoring of urine output for signs and symptoms of infection. The DON stated residents with indwelling catheters need catheter care, assessment for signs and symptoms of infection, and monitoring of urine output to prevent UTI. Resident 50’s record showed a neurogenic bladder and an indwelling catheter, but the order summary only included an order to cleanse the suprapubic catheter site daily. There was no order for the suprapubic catheter itself with an indication for use, and no monitoring was in place to ensure the suprapubic catheter was present and that the resident was being monitored for UTI. During interview, the MDS Nurse stated there were no orders for the suprapubic catheter but there should have been one, and that staff should have had monitoring in place for infection, bleeding, leaking, and sediment. The DON also stated there should have been a physician order for any type of indwelling catheter use with indication and monitoring in place. The facility policy titled Catheter Care, Urinary, revised 1/2026, stated the purpose was to prevent catheter-associated complications including UTIs and directed staff to observe urine for unusual appearance, bleeding, burning, tenderness, or pain, provide routine perineal hygiene, and document all care rendered and assessment of urine characteristics and problems. The policy also stated clinical indications for catheter use should be reviewed and documented prior to insertion and that ongoing need should be assessed and documented using a standardized tool. The records and interviews showed these expectations were not met for the sampled residents.
Dialysis Access and Hemodialysis Care Not Followed
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for three residents who required hemodialysis and had AV access sites. For Resident 6 and Resident 103, staff obtained blood pressure readings on the left upper extremity even though each resident had an order not to take blood pressure on the arm with the AV shunt. Resident 6’s care plan also directed staff not to take blood pressure in the arm with the graft, yet the record showed repeated left-arm blood pressure measurements over multiple dates. Resident 103’s record likewise showed left upper arm blood pressure readings on several occasions, and the Infection Prevention Nurse confirmed that blood pressure should not have been taken from that arm. Resident 6 was admitted with ESRD and dependence on hemodialysis, and the MDS showed moderately impaired cognition with varying levels of assistance needed for daily care. The record showed that Resident 6 missed scheduled dialysis treatments on 2/17/2026 and 2/19/2026. The Assistant Director of Nursing confirmed that a Change of Condition assessment was not completed after the missed treatments, including notifying the physician, assessing the resident for risks related to missed hemodialysis, contacting the dialysis center to reschedule, and monitoring the resident for potential complications after missing dialysis. The DON stated staff needed to complete a COC when residents missed HD and that missed HD placed the resident at risk for fluid overload. Resident 1 was admitted with ESRD and dependence on renal dialysis, and the MDS showed severe cognitive impairment with dependence for several activities of daily living. The hospital record identified two AV shunts in the right upper arm and a central line in the left internal jugular. During observation and record review, staff confirmed the resident had an old AV shunt on the right arm and that the current dialysis access was the perma catheter in the left upper chest, but the resident’s blood pressure was taken in the right arm on several occasions. Staff also stated there was no documentation for the second AV shunt and that assessments should include skin assessment and documentation of the AV shunt, including monitoring for bleeding and patency.
Expired inhaler stored and administered after expiration
Penalty
Summary
The facility failed to ensure that an expired fluticasone furoate Ellipta oral inhaler was not stored in MedCart 2A on Station 2 and was administered to a resident after expiration. Resident 79 was admitted and later readmitted with diagnoses including asthma, COPD, interstitial pulmonary disease, and acute respiratory failure with hypoxia. The resident’s H&P stated the resident had the capacity to understand and make decisions. The resident had an active order for fluticasone furoate inhalation aerosol powder, one puff orally daily for shortness of breath. During observation and interview, the inhaler was found in MedCart 2A with an open date recorded, and LVN 2 reviewed the manufacturer labeling and stated the inhaler expired six weeks after opening. LVN 2 stated the resident’s inhaler had expired and that a dose was administered that day. The ADON also stated the inhaler had expired and needed replacement. Review of the MAR and Administration Detail Report showed the resident received two doses after the expiration date. The DON confirmed the inhaler was first opened on the recorded date, expired on the recorded expiration date, and was documented as administered twice after expiration.
Failure to Follow Up on Recommended Thyroid Ultrasound
Penalty
Summary
The facility failed to follow up on a recommendation for an ultrasound of Resident 101’s right thyroid nodule for diagnostic testing. Resident 101 was admitted with diagnoses including spondylosis with myelopathy in the cervical region, disorder of bone density and structure, and osteoarthritis in both hands. The resident’s H&P stated the resident had the capacity to understand and make medical decisions, and the MDS indicated the resident was cognitively intact and required varying levels of assistance with activities of daily living. Pacific Rehab Consultants PM&R follow-up notes repeatedly documented that an ultrasound was recommended due to the right thyroid nodule and that the recommendation was discussed with nursing and would be scheduled. These notes were dated 11/26/2025, 12/4/2025, 12/19/2025, 1/27/2026, and 3/10/2026. During interview, the ADON stated nurses read the PM&R follow-up notes and that any orders would be placed by the PA, and acknowledged that the recommendation should have been clarified with the doctor and followed up to determine whether the diagnostic testing had been completed. The DON stated that if a recommendation was not followed up, the facility would not be able to provide the right treatment and interventions for Resident 101.
Failure to Provide Ordered RNA Services
Penalty
Summary
The facility failed to ensure one of seven sampled residents received restorative nursing assistant (RNA) services as ordered by the physician. Resident 101 was admitted with diagnoses including spondylosis with myelopathy in the cervical region, disorder of bone density and structure, and osteoarthritis in both hands. The resident’s H&P indicated the resident had the capacity to understand and make medical decisions, and the MDS indicated the resident was cognitively intact. The MDS also showed the resident was dependent for shower transfer and chair/bed-to-chair transfer, required substantial assistance for lower body dressing, and needed help with personal hygiene. The order summary report showed orders for RNA active assistive range of motion to both lower extremities three times a week, RNA application of an abductor wedge with skin checks three times a week, and an RNA program for a right resting hand splint three times a week. During interview and record review, the DSD confirmed missing documentation for multiple scheduled RNA services, including no documentation for bilateral upper and lower extremity ROM on 2/14/2026, no documentation for the right hand splint on 2/21/2026, and no documentation for the abductor wedge on 2/28/2026. The DSD stated that if it was not documented, then it was not done, and said the RNAs were present every day and could provide the service the following day if needed. The DON stated the RNA services were important to prevent further decline and overall functional ability. The facility policy stated residents would receive restorative nursing care as needed to help promote optimal safety and independence.
Failure to Obtain Representative Consent for Arbitration Agreement
Penalty
Summary
The facility failed to obtain consent for a binding arbitration agreement from the resident representative for one of three sampled residents, Resident 19, who did not have the capacity to make decisions. Resident 19’s record showed admission on 11/14/2001 and re-admission on [DATE] with diagnoses including metabolic encephalopathy. The MDS dated 10/30/2024 and 3/26/2026 indicated severely impaired cognition, and the H&P dated 10/25/2024 noted fluctuating capacity to understand and make decisions, while the H&P dated 1/23/2026 stated the resident did not have capacity to understand and make decisions. The arbitration agreement dated 10/24/2024 contained Resident 19’s signature. During interviews, the AD and AA stated the arbitration agreement is explained at admission and that the resident nodded when it was explained, but they did not verify whether the resident lacked capacity or check with nursing staff about the resident’s ability to make an informed decision. The AD stated the importance of making the resident or responsible party aware that signing the arbitration agreement means giving up the right to go to court. The DON stated that if a resident lacks capacity, signing the arbitration agreement would not be accurate. The facility policy stated the resident or representative must be given the terms in a manner understood, must verbally acknowledge understanding, and that a signature alone is not sufficient.
QAPI Committee Failed to Address Systemic Care Planning, PASARR, and MDS Deficiencies
Penalty
Summary
The facility's QAPI Committee failed to identify and implement corrective action for systemic problems that affected 173 of 173 residents. The deficiencies identified were the failure to ensure person-centered care plans were initiated and implemented for every resident, the failure to ensure PASARR was completed in a timely manner, and the failure to ensure MDS assessments were accurate according to residents' needs and services. During interview, the Administrator stated the systemic issues were not identified by the QAPI committee and that the facility failed to ensure person-centered care plans were initiated and implemented for each resident, PASARR was done in a timely manner, and MDS assessments were accurate. The Administrator also stated the facility should have completed QAPI for the deficiencies from the last survey process so the same deficiencies would not repeat, and acknowledged he was not aware the QAPI committee had to do that. The facility policy titled Quality Assurance and Performance Improvement Program, dated January 2026, stated the QAPI program shall be ongoing, facility-wide, and data-driven, and shall provide a means to measure indicators, establish performance improvement projects, reinforce effective systems and processes, and monitor and evaluate corrective actions.
Failure to follow infection control practices for staff vaccination, PPE use, and respiratory equipment
Penalty
Summary
The facility failed to document evidence that 32 of 32 licensed practitioners received annual influenza vaccine status review, education on the benefits and potential side effects of the 2025 to 2026 flu vaccine, and an offer of the current flu vaccine. During review of the staff vaccination binders, the Infection Prevention Nurse stated there was no documented evidence that physicians or licensed practitioners were educated on benefits and side effects or offered the 2025 to 2026 flu vaccine, and stated flu vaccination status for physicians should also be obtained because they have direct access to residents. The DON stated staff need to be educated and offered the current annual flu vaccine because vaccines minimize sickness and protect residents in the facility. The facility also failed to ensure an LVN wore PPE during direct contact with two residents who had indwelling medical devices. Resident 114 was admitted with diagnoses including a G-tube, dysphagia, and type 2 diabetes mellitus, and the H&P stated the resident did not have the capacity to understand and make medical decisions. The MDS indicated moderate cognitive impairment and dependence on staff for multiple activities of daily living. During observation, the resident’s tube feeding was turned off but remained attached to the G-tube, and the LVN assessed and had direct contact with the G-tube without wearing proper PPE. The LVN stated PPE is worn when changing the foley, G-tube, feeding, or when touching the resident, and stated she should have worn a gown when touching the G-tube and foley catheter. The facility further failed to ensure PPE was worn when the same LVN assessed Resident 46’s indwelling catheter and touched the foley bag attached to the bed. Resident 46’s record showed diagnoses including hydronephrosis, urinary retention, and neuromuscular dysfunction of the bladder, and the MDS indicated severe cognitive impairment with dependence or assistance needed for several activities of daily living. The DON stated EBP is implemented when a resident has a foley catheter or tube feeding, and that wearing a gown prevents residents from getting an infection and prevents cross contamination. In addition, the facility failed to ensure Resident 27’s handheld nebulizer tubing was changed weekly. Resident 27 had COPD, chronic pulmonary edema, and respiratory failure, and the MDS indicated moderately impaired cognition. The nebulizer tubing and bag were labeled with a date from more than a week earlier, and the resident stated the nebulizer had been used about one hour before the observation. The LVN confirmed the tubing had been in use since that date and stated the tubing should be changed weekly to prevent infection control.
Failure to Document Vital Signs and Nursing Interventions During Resident’s Acute Bleeding Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure licensed nurses documented vital signs and nursing interventions in accordance with professional standards when a resident experienced a significant change in condition characterized by coughing up blood. The resident had a history of cerebrovascular disease and seizures, was unable to make reasonable decisions per the MDS, and was receiving Eliquis via gastrostomy tube with a care plan identifying risk for bleeding and requiring prompt identification and response to signs of blood loss. On the date of the incident, an SBAR form at 8:40 a.m. documented that the resident was coughing up blood with a blood pressure of 163/97 mmHg, and a nurse’s note at 9:02 a.m. recorded that the resident was coughing a moderate amount of blood with the same blood pressure and that the physician was notified with orders to transfer the resident to a hospital. Subsequent nurse’s notes at 9:04 a.m. documented that a private BLS ambulance was called with an expected arrival time between 11:30 a.m. and 12 p.m. Later documentation at 12:05 p.m. indicated the resident was coughing more blood, had a clenched jaw, and required continuous oral suctioning, and that the private ambulance crew advised staff to call 911 for an emergency transfer. The paramedic run sheet recorded that EMS found the resident with uncontrolled bleeding from the mouth due to a tongue bite, with vital signs including blood pressure 162/94 mmHg, heart rate 70 BPM, respiratory rate 20, and oxygen saturation 96%, and that approximately 800–1,000 mL of blood was suctioned during transport. Hospital emergency department records documented profuse tongue bleeding and elevated blood pressure on arrival. Review of the facility’s Weights and Vitals Summary for that day showed vital signs documented at 8:27 a.m. and 11:46 a.m., but there was no documentation of vital signs or monitoring at 8:40 a.m. when the resident was noted to be coughing blood, nor documentation of nursing interventions at that specific time related to the change in condition. The facility’s policy on Change in a Resident’s Condition or Status required licensed nurses to identify worsening conditions, promptly notify the physician, alter treatment as needed including transfer, and document all information related to changes in condition in the medical record. The surveyors found that, despite the documented change in condition and subsequent deterioration, the medical record lacked documentation of vital signs and monitoring at the time the resident was first reported to be coughing up blood, constituting a failure to maintain complete medical records in line with accepted professional standards.
Failure to Provide Adequate Supervision and Safety Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and implementation of safety interventions for a resident with poor safety awareness, a history of falls, and moderate fall risk. The resident, who had severe cognitive impairment, was fully dependent on staff for activities of daily living and had a care plan requiring supervision at the nurses' station. Despite these documented needs, the resident was left in a wheelchair in the hallway, not within arm's reach or direct observation of staff. On the day of the incident, the resident attempted to stand up from her wheelchair unassisted. A CNA, who was several feet away, saw the resident trying to get up and shouted for her to stop, but was unable to reach her in time. The resident did not respond to verbal cues and fell to the floor, landing on her right side. The RN present at the nurses' station was not actively observing the resident and was also unable to intervene in time to prevent the fall. Interviews and record reviews confirmed that the staff did not provide the necessary redirection, cueing, or close supervision as outlined in the resident's care plan and the facility's policies. The facility's policies required individualized interventions and consistent implementation of safety measures for residents at risk of falls, but these were not followed, resulting in the resident's fall and subsequent transfer for further evaluation.
Failure to Follow Up on Podiatry Referral for Resident with Diabetes and Renal Failure
Penalty
Summary
The facility failed to follow up on a podiatry consultation referral for one resident who was admitted with diagnoses including Type 2 diabetes mellitus and dependence on renal dialysis. The resident's admission orders included a consultation to podiatry for mycotic hypertrophic nails and/or keratotic lesions. Despite the referral being approved, the resident did not receive podiatry services due to insurance denials and a transition to new coverage. The facility did not offer private-pay podiatry services while awaiting authorization approval. Interviews with facility staff confirmed that proper nail care and hygiene were expected, especially for residents with long toenails, as ingrown toenails can lead to infection and skin breakdown. The Social Service Director acknowledged the delay in podiatry services and the lack of alternative arrangements during the insurance transition. Review of facility policy indicated that the Social Services Director was responsible for assisting in obtaining necessary health services, including podiatry, to meet resident needs.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
A resident with diagnoses including hyperlipidemia and type 2 diabetes mellitus was admitted to the facility and required a therapeutic diet, specifically a renal 80-gram protein, regular texture, thin liquids, controlled carbohydrate, double portion protein diet. The resident's dietary preferences, documented during the admission process, included a request for wheat bread instead of white bread and no cheese. Despite these documented preferences, the resident was repeatedly served white bread and pasta, contrary to their requests. The resident expressed frustration and concern about the lack of accommodation for their food preferences, stating that dietary staff were not honoring their requests. The Dietary Supervisor confirmed that the last dietary preference assessment reflected the resident's requests and acknowledged a mistake in serving white bread. The supervisor explained that tray line staff were responsible for checking menu cards with meal trays and recognized the importance of honoring resident food preferences. Facility policy indicated that reasonable efforts would be made to accommodate resident choices and preferences, but this was not followed in this instance, resulting in the resident not receiving meals consistent with their documented preferences.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Inaccurate MDS Coding for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the use of antipsychotic medication for a resident. Record review showed that the resident, who had diagnoses including encephalopathy, diabetes mellitus type 2, and depression, was prescribed Seroquel (an antipsychotic) in two different dosages for psychosis-related behaviors. However, the MDS assessment did not indicate that the resident was receiving any antipsychotic medication. This discrepancy was confirmed during interviews with both the MDS Director and the Director of Nursing, who acknowledged that the MDS was not coded accurately. The inaccurate MDS assessment meant that the resident's use of antipsychotic medication was not properly documented, which could affect the resident's plan of care and the delivery of services. The facility's policy requires comprehensive and accurate assessments at designated intervals, and all staff completing any portion of the MDS must attest to the accuracy of the information. The failure to accurately code the MDS assessment was identified through both record review and staff interviews.
Failure to Update Care Plan with Fall Prevention Intervention
Penalty
Summary
The facility failed to revise and implement a comprehensive care plan for a resident assessed as high risk for falls. The resident, who had a history of falls, a right femur fracture, dementia, and severe cognitive impairment, was dependent on staff for all activities of daily living. After an unwitnessed fall, the interdisciplinary team (IDT) recommended the use of non-skid socks during ambulation to reduce fall risk. However, this intervention was not incorporated into the resident's care plan, despite being discussed and agreed upon during an IDT meeting. Interviews with facility staff, including the Quality Assurance nurse and the Director of Nursing (DON), confirmed that the recommendation for non-skid socks was not added to the resident's fall risk care plan. The facility's policy requires care plans to be updated when there is a significant change in the resident's condition or after relevant team recommendations, but this process was not followed. As a result, the resident's care plan did not reflect all necessary interventions to address their identified fall risk.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a midline catheter who required infection control measures to reduce the spread of multidrug-resistant organisms (MDROs). The resident, who had severe cognitive impairment and was always incontinent of bladder and bowel, was admitted with multiple diagnoses and was receiving intravenous Vancomycin through a midline in her right upper arm. The care plan specified that staff should use personal protective equipment (PPE) such as gown and gloves during high-contact care activities, including toileting and changing briefs, and that appropriate signage should be posted to alert staff to the EBP requirements. During observations and interviews, it was found that there was no EBP signage outside the resident's room or above her bed, and a CNA caring for the resident was unaware she was on EBP, mistakenly believing it was her roommate. The CNA did not use PPE when toileting the resident, and later acknowledged this was an error. The Infection Preventionist and DON confirmed that PPE should have been used for high-contact care activities for this resident. Review of facility policy also indicated that EBP, including gown and gloves, should be used for residents with indwelling medical devices during high-contact care.
Failure to Properly Document and Offer Advance Directives for Residents Lacking Capacity
Penalty
Summary
The facility failed to ensure that residents' medical records were up to date regarding advance directives (AD) in accordance with its own policy and procedure. For two of six sampled residents, the facility did not properly document whether the residents or their representatives were informed of the option to formulate an AD, nor did they obtain the required signatures to acknowledge that this information was provided. In one case, a resident with severe cognitive impairment and no decision-making capacity had an AD acknowledgment form that was unsigned by either the resident or their representative, despite the family being contacted and declining to formulate an AD. The form lacked clarity on whether the information was provided in person or by phone, and did not include the necessary staff signatures as per facility policy. Another resident, also with severe cognitive impairment and a designated responsible party, had an AD acknowledgment form signed only by facility staff and the physician, but not by the responsible party. The responsible party was not given the opportunity to execute or formulate an advance directive, and there was no documented follow-up with them. Both the Social Services Director and the Director of Nursing confirmed during interviews that the process for offering and documenting advance directives was not properly followed when residents lacked capacity, and that the responsible parties should have been involved and provided with the necessary information. The facility's policy required that residents or their legal representatives be provided with written information about the right to accept or refuse medical or surgical treatment and to formulate an advance directive. It also required that information about the existence of an advance directive be clearly documented and retrievable in the medical record. The failure to follow these procedures resulted in incomplete documentation and a lack of clarity regarding whether residents' or their representatives' wishes were known and could be honored.
Failure to Implement PASARR Recommendations for Psychiatry Consultation
Penalty
Summary
The facility failed to implement recommendations from the Level II Preadmission Screening and Resident Review (PASARR) for one resident. The resident, who had a diagnosis of unspecified psychosis and was moderately impaired in cognition, required supervision for eating and moderate assistance with toileting, bathing, and dressing. The PASARR Individualized Determination Report recommended a psychiatry consultation and/or follow-up care for this resident. Upon review, it was found that there were no orders or care plans indicating a consult to psychiatry for the resident, despite the PASARR recommendations. The facility's policy required that care plans include specialized services resulting from PASARR recommendations, but this was not reflected in the resident's care plan or medical orders. Interviews with facility staff confirmed the lack of follow-up on the PASARR recommendations.
Failure to Complete Required PASRR Level 2 Evaluation for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to follow through with the federally mandated Preadmission Screening and Resident Review (PASRR) process for one resident who was admitted and readmitted with multiple mental health diagnoses, including paranoid schizophrenia, bipolar disorder, schizoaffective disorder, anxiety disorder, and mild cognitive impairment. The resident's PASRR Level 1 screening was positive for suspected mental illness, indicating the need for a Level 2 evaluation. However, the Department of Health Care Services closed the case after determining the resident was unable to participate in the Level 2 evaluation, and no further action was taken by the facility to resubmit a new Level 1 screening to reopen the case. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the facility did not resubmit the required PASRR Level 1 screening after the initial Level 2 evaluation was not completed. Both the ADON and DON acknowledged the importance of the PASRR process in ensuring residents with mental or developmental disorders receive appropriate placement and services, and that the facility's policy required referral for Level 2 screening when indicated by a positive Level 1 result. The failure to follow up resulted in the resident not receiving the necessary PASRR Level 2 evaluation as required.
Failure to Develop and Implement Comprehensive, Individualized Care Plans and Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive care plans and to follow existing care plan interventions for multiple residents, resulting in deficiencies related to medication monitoring, fall prevention, and the use of safety devices. For one resident with a seizure disorder, staff did not monitor or document the effectiveness and side effects of multiple prescribed seizure medications, despite care plan directives to do so. Review of the resident's records and interviews with staff confirmed the absence of required documentation for two months, and the MDS Coordinator acknowledged that this monitoring should have been performed and recorded during each shift. Another resident with severe cognitive impairment had a bed sensor alarm in place as ordered, but the comprehensive care plan did not include this intervention. Observations confirmed the presence of the alarm, but the care plan lacked any mention of it, and both the MDS Coordinator and DON stated that the care plan should have been individualized to include this device and guide staff in its use and monitoring. Similarly, a resident prescribed a psychotropic medication did not have a baseline care plan addressing the medication, as confirmed by record review and staff interviews. Additional deficiencies included the failure to provide bilateral bed bolsters for a resident at risk for falls, as indicated in the care plan, and the failure to keep the head of the bed elevated for a resident receiving enteral nutrition, as required to reduce aspiration risk. Observations showed the resident without bed bolsters and lying flat during tube feeding. For another resident at high risk for falls, the facility did not implement the 'falling star' identifier as required by the care plan and facility policy, and the care plan did not include all interventions in use, such as a bed alarm. Staff interviews and record reviews confirmed these omissions, and facility policies required that care plans be comprehensive, person-centered, and updated to reflect all interventions in use.
Failure to Document E-Kit Usage and Review Cubex Reports
Penalty
Summary
The facility failed to document the usage of the Emergency kit (E-Kit) on the designated log. During an observation in the medication room, a licensed vocational nurse presented a binder containing a loose yellow slip dated earlier in the year and pharmacy log forms organized by month. Upon review, the E-kit pharmacy log for January was found to be blank, and the nurse confirmed that the information from the yellow slip should have been entered into the log. The facility's Emergency Kit Pharmacy Log instructions required complete entry of information, but this was not followed. Additionally, the facility's policy and procedure for Emergency kit usage did not specify the state regulation requirement for maintaining separate records of use. The facility also failed to receive and review daily activity and discrepancy reports from the Cubex automated medication dispensing system for at least four months. The current DON stated that since starting employment, no Cubex activity reports had been received from the pharmacy, although the previous DON had been receiving them. The administrator confirmed that the previous DON left the position prior to the current DON's start date. Facility policy required the DON to review generated discrepancy reports to investigate nursing activity and resolve discrepancies, as well as to retain controlled substance activity reports, but these procedures were not followed.
Failure to Provide and Follow Up on Dental Services for Two Residents
Penalty
Summary
The facility failed to provide and follow up on dental services for two residents, resulting in deficiencies related to oral health care. For one resident with dysphagia and dementia, there was no documented follow-up or communication regarding the status of her requested partial denture. Despite an initial dental x-ray and insurance authorization attempt, there was a lack of ongoing documentation or updates to the resident or her responsible party about the denture request. The resident expressed discomfort while eating and embarrassment due to missing teeth, and staff interviews confirmed that follow-up and documentation were not completed as required. Another resident with diabetes, end stage renal failure, and major depressive disorder was not assisted in obtaining a new upper partial denture after expressing dissatisfaction with her current denture. The onsite dentist recommended a new denture if eligible, but there was no evidence of follow-up with either the outside or onsite dental provider for authorization or further action. The resident reported not wearing her dentures due to poor fit and feeling embarrassed about her appearance, and staff acknowledged the lack of documented follow-up. Record reviews and staff interviews revealed that the facility's policies required social services to assist with dental appointments and ensure all dental services were recorded in the medical record. However, in both cases, there was a failure to coordinate, document, and communicate necessary dental care and follow-up, as well as to inform the residents and their responsible parties about the status of their dental needs.
Call Light Not Within Reach for High Fall Risk Resident
Penalty
Summary
A deficiency was identified when a resident, who was a high fall risk and severely cognitively impaired, was observed lying in bed with her call light on the floor and out of her reach. The resident had significant medical conditions, including metabolic encephalopathy, respiratory failure, end stage renal disease, and anxiety disorder, and was dependent on staff for mobility and self-care needs. The resident's Minimum Data Set indicated she required moderate to total assistance for daily activities and did not have the capacity to make decisions. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that call lights are required to be within reach of residents, especially those at high risk for falls, to ensure they can summon help when needed. The facility's policy also stated that call lights should be within easy reach of residents in bed or confined to a chair. The failure to ensure the call light was accessible constituted a deficiency in accommodating the resident's needs and preferences.
Failure to Assess, Monitor, and Document Bed Alarm Use as a Restraint
Penalty
Summary
A deficiency occurred when a resident with dementia, open angle glaucoma, and a history of falls was subjected to the use of a bed alarm without proper assessment, monitoring, or documentation. The resident, who required significant assistance for daily activities and had no capacity to make decisions, reported discomfort and poor sleep due to the loudness of the alarm, which he could not turn off. The alarm was used to prevent falls, but there was no evidence of a physician's order, informed consent, or care plan addressing its use. Staff interviews revealed that the bed alarm was implemented based on the belief that the resident was at high risk for falls, but neither the Assistant Director of Nursing nor the Minimum Data Set Coordinator were aware of its use. The alarm was not coded in the resident's assessment or included in the care plan, and there was no documentation of monitoring or physician authorization in the resident's records. The facility's policy required a pre-restraining assessment, physician order, and consent for any device considered a restraint, but these steps were not followed. The Director of Nursing confirmed that the bed alarm, which restricted the resident's movement and caused discomfort, should have been considered a restraint and required proper assessment and documentation. The lack of assessment, monitoring, and documentation for the use of the bed alarm constituted a failure to ensure the resident was free from unnecessary physical restraints, as required by facility policy and regulatory standards.
Inaccurate MDS Documentation for Resident with Psychosis
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately documented for one resident. The resident in question was admitted and later readmitted with a diagnosis that included unspecified psychosis. The resident's MDS, however, did not indicate the presence of a psychotic disorder, despite the resident having a physician's order for Olanzapine, an antipsychotic medication prescribed for psychosis manifested by angry outbursts. The MDS Coordinator confirmed during an interview that the MDS should have reflected the resident's diagnosis of psychosis, given the medication order and documented diagnosis. Further review of the facility's policy and procedure on charting and documentation revealed that documentation in the medical record is required to be objective, complete, and accurate. The Director of Nursing also stated the importance of patient-specific and accurate MDS assessments to ensure appropriate treatment and care planning. The failure to accurately document the resident's psychotic disorder on the MDS represents a deficiency in the facility's assessment and documentation practices.
Missed Quarterly IDT Meeting for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident received quarterly Interdisciplinary Team (IDT) meetings as required. According to the resident's admission record, the individual was admitted with a diagnosis of major depressive disorder and had moderate cognitive impairment, requiring varying levels of assistance with daily activities. During an interview, the resident expressed not knowing her plan of care and not being informed about when she could leave the facility. A review of the Minimum Data Set (MDS) and IDT meeting records revealed that the resident had IDT meetings on two specific dates, but missed the required quarterly meeting in November, as confirmed by the Assistant Director of Nursing (ADON). The Director of Nursing (DON) stated that IDT meetings are conducted on admission, quarterly, and as needed for changes in condition, emphasizing their importance for updating residents on their care plans and addressing concerns. The facility's policy also requires the IDT to review and update care plans at least quarterly in conjunction with the required MDS assessment. The failure to hold the quarterly IDT meeting resulted in the resident not being kept informed about her care plan and not having her concerns addressed in a timely manner.
Failure to Maintain Head of Bed Elevation During Tube Feeding
Penalty
Summary
The facility failed to follow professional standards of care by not ensuring that a resident receiving tube feeding had the head of bed (HOB) elevated at least 30 degrees while the feeding was in progress. The resident, who had a history of seizures, gastrostomy, dysphagia, and pneumonitis due to aspiration, was identified as being at risk for tube feeding complications, including aspiration pneumonia. The resident's care plan specifically included the intervention to keep the HOB elevated at least 30 degrees during tube feeding. On the day of the observation, the resident was found lying flat in bed with tube feeding running at 50 ml/hr. A licensed vocational nurse entered the room, noticed the resident was supine, and then elevated the HOB to 30 degrees. Facility staff, including the assistant director of nursing, confirmed the importance of maintaining HOB elevation for residents receiving tube feeding to prevent complications. The facility's policy also addressed the need for proper positioning to reduce aspiration risk.
Failure to Maintain Resident Grooming and Hygiene
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming and personal hygiene for a resident who was dependent on staff for activities of daily living (ADLs). The resident, who had diagnoses including dementia, cerebral infarction, and Type II Diabetes Mellitus, was assessed as having moderately impaired cognitive skills and required moderate assistance for eating and was dependent on staff for all other ADLs, including bathing, toileting hygiene, transfers, oral hygiene, dressing, and personal hygiene. During observations, the resident was found with unkempt fingernails that had a fecal matter odor and a black substance underneath the nails on both hands. Interviews with a CNA and the DON confirmed that nail care, including cleaning and trimming, is part of routine hygiene care and is necessary to prevent scratches, skin tears, abrasions, and potential infections. Facility policies reviewed indicated that daily cleaning and regular trimming of nails are required to prevent infections and maintain hygiene. Despite these policies and the resident's dependence on staff for ADLs, the resident's fingernails were not properly maintained, resulting in the observed deficiency.
Failure to Provide Care-Plan-Directed Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident with a history of falls and significant physical limitations had bilateral bed bolsters in place as recommended by the interdisciplinary team and documented in the care plan. The resident, who was totally dependent on staff for bed mobility and transfers and had diagnoses including hemiplegia following a stroke, lack of coordination, and seizures, experienced a fall resulting in minor injuries. Following this incident, the care plan and IDT notes specified the use of bilateral bed bolsters to minimize fall risk. Upon the resident's readmission from a general acute care hospital, the order for bilateral bed bolsters was not reentered, and the intervention was not implemented, despite its inclusion in the care plan. Observations confirmed that the resident was found in bed without the required bolsters and was leaning off the side of the bed. Staff interviews revealed that the omission was due to the order being overlooked during the readmission process, resulting in the resident not receiving the planned fall prevention intervention.
Deficient Food Storage, Labeling, and Sanitation Practices in Dietary Services
Penalty
Summary
The facility failed to store, label, and monitor food items in accordance with professional standards and its own policies, as observed during surveyor visits. Multiple food items in dry storage and refrigerators were found to be improperly labeled, lacking receiving, opening, or use-by dates, and in some cases, not properly sealed. Opened products such as white chocolates, shredded coconut, dry pasta, barleys, sugar, and fudge brownie mix were missing required dates and were not always tightly closed. In the walk-in refrigerator, items like thickened lemon flavor, tomato juice, prepared yogurt, apple sauce, and fruit punch were also missing appropriate labeling and use-by dates. Additionally, expired cottage cheese was found, which should have been discarded according to the facility's own storage guidelines. The facility also failed to consistently monitor and document the temperature of a small freezer in the dry storage area, as evidenced by a blank temperature log for a specific date. According to facility policy, freezer temperatures are required to be recorded twice daily to ensure food safety. Furthermore, the concentration of quaternary ammonium in a sanitizing bucket was found to be below the required 200 ppm, and staff did not consistently test or replace the solution as outlined in policy, potentially compromising the effectiveness of surface sanitization in the kitchen. During meal preparation, a dietary aide was observed wearing a wristwatch that was not covered by gloves while rinsing dishes, contrary to the facility's dress code policy, which requires jewelry and wristwatches to be removed or fully covered when handling food. The dietary aide was unaware of this policy, and the gloves provided were not long enough to cover the wristwatch. The dietary supervisor confirmed that proper hand hygiene and PPE use, including removal or coverage of jewelry, are required to prevent cross-contamination during food handling.
Failure to Perform Hand Hygiene During Tray Checks
Penalty
Summary
A Quality Assurance Nurse (QAN) failed to perform hand hygiene while checking lunch trays in the dining room. During the process, the QAN handled the lunch tray cart, including touching the metal closure and door, and then proceeded to touch additional trays and food items without sanitizing her hands. The QAN acknowledged during the interview that she did not realize she was cross-contaminating and stated that hand hygiene should be performed between tasks and after touching other surfaces to prevent the spread of infection. Interviews with the Infection Preventionist Nurse (IPN) and the Director of Nursing (DON) confirmed that facility policy requires hand hygiene between tasks and after contact with high-touch surfaces. The facility's policy and procedure on hand hygiene, reviewed in February 2025, states that all personnel are expected to adhere to hand hygiene practices to prevent the spread of healthcare-associated infections, specifically after touching contaminated surfaces or the resident's environment. The QAN's failure to follow these protocols constituted a breach of infection control measures.
Failure to Follow Antibiotic Stewardship Policy for Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program policy when an antibiotic was prescribed to a resident without meeting established criteria for appropriate use. Specifically, a resident with a history of hemiplegia, hemiparesis following a stroke, and sepsis was prescribed doxycycline for sepsis. Upon review, the Infection Preventionist Nurse (IPN) determined that the infection did not meet Loeb's or McGeer's Criteria for antibiotic use, as documented in the Infection Screening Evaluation. Despite this, there was no documentation that the physician was notified about the lack of criteria being met, as required by facility policy. Interviews with the IPN and the Director of Nursing (DON) confirmed that the physician should have been informed when the criteria were not met, but this step was not taken. The facility's policy states that the IPN is responsible for collecting, analyzing, and providing infection and antibiotic usage data to nursing staff and healthcare practitioners, but this process was not followed in this instance. The failure to notify the physician and adhere to the antibiotic stewardship policy resulted in a deficiency related to the monitoring and appropriate use of antibiotics.
Failure to Document and Track Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to provide documented evidence of employee screening, education, offering, and current COVID-19 vaccination status for all staff members. During interviews, the Infection Prevention Nurse (IPN) admitted that she had not completed auditing the vaccination status of employees and did not have easy access to the vaccination records for certain staff, such as a Certified Nursing Assistant (CNA). The IPN also stated that she did not have the COVID-19 vaccination status for the medical director and consultants. The Director of Nursing (DON) confirmed that the facility keeps employee COVID-19 records for safety and infection control, but the report did not show that all staff vaccination statuses were documented and readily available. A review of the facility's policy and procedure indicated that all staff, including employees, licensed practitioners, students, volunteers, and contracted personnel, are required to provide documentation of their vaccination status. The infection preventionist is responsible for maintaining a tracking worksheet with the most current vaccination status for all staff. However, the findings revealed that this process was not fully implemented, as the facility could not provide complete and up-to-date documentation for all required individuals.
Failure to Honor Residents' Right to Choose Attending Physician
Penalty
Summary
The facility failed to honor the residents' right to choose their attending physician, as evidenced by the lack of communication and documentation regarding the change of primary care physician (PCP) for five residents. The facility did not verbally confirm with the original PCP that he was no longer returning to the facility, nor did they follow their policy to inform residents in writing about the change in their attending physician. This resulted in residents being informed that their physician was changed without their consent or proper notification, disrupting the continuity of care. Resident 1, who lacked the capacity to make decisions, was informed by their responsible party that the PCP was no longer seeing patients at the facility, and a new physician was assigned without a request for change. Resident 2, who was self-responsible, had a progress note from the original PCP expressing confusion over the change, indicating the resident did not request a new doctor. Resident 3, who had decision-making capacity, was informed via text and phone call about the change but did not receive any documentation with the new PCP's contact information. Residents 4 and 5, both self-responsible, also did not receive written notification of the new PCP's contact information. The facility's administrator and director of nursing did not clarify the original PCP's intentions when he expressed frustration and stated he would not return, leading to an assumption that the PCP had left permanently. The facility's policy required written notification of any changes in attending physician, which was not adhered to, resulting in a failure to respect the residents' rights to choose their physician.
Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident who experienced an unwitnessed fall. The resident, who had a history of falls and a subdural hemorrhage, was found on the floor by a CNA but did not receive a proper post-fall assessment or pain management. LVN 1 did not report the fall to the resident's physician, which delayed the prescription and administration of pain medication. Additionally, LVN 1 did not conduct a thorough assessment to determine if the resident had sustained any injuries or to evaluate the resident's pain level. The situation was exacerbated when the physical therapist, PT 1, reported that the resident was in significant pain and guarding her left hip during an evaluation. Despite this, LVN 1 failed to communicate these findings to the resident's physician or RNS 1. It was only after the resident's responsible party (RP) visited and observed the resident in excruciating pain that emergency services were called. The resident was eventually transferred to a general acute care hospital (GACH) where she was diagnosed with a comminuted left intertrochanteric fracture and underwent surgery. Interviews with facility staff, including CNA 1, LVN 1, RNS 1, and the Director of Nursing (DON), revealed a lack of communication and failure to follow the facility's policies and procedures regarding pain assessment and change in condition. The DON acknowledged that LVN 1 should have notified the appropriate personnel and the resident's physician immediately after the fall. The facility's policies required staff to assess pain upon admission, during significant changes in condition, and to notify the physician of any incidents or changes in the resident's status.
Failure to Notify Physician and Family After Resident's Fall
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) notified the physician and the Responsible Party (RP) for a resident who sustained an unwitnessed fall and complained of severe pain. This deficiency resulted in the resident being found on the floor, experiencing unrelieved pain for approximately two hours, and the RP and physician being unaware of the fall, causing a delay in care. The resident, who had a history of falls and subdural hemorrhage, was admitted to the facility and required assistance with transfers and activities of daily living. On the day of the incident, the resident was found on the floor by facility staff, unable to explain the fall, and initially reported as having no pain. However, a Joint Mobility Screen indicated the resident was guarding and holding her left leg, screaming in pain. The RP discovered the resident in excruciating pain during a visit and requested emergency services, as the facility staff had not informed him of the fall. Interviews revealed that the LVN did not notify the RP or the physician about the fall due to a perceived communication barrier with the RP. The Registered Nurse Supervisor (RNS) and the Director of Nursing (DON) confirmed that the LVN should have reported the fall to the physician and the RP. The facility's policy required notification of the physician and family or representative in the event of a significant change in the resident's condition, which was not followed in this case.
Failure to Ensure Competency in Fall Assessment and Reporting
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) was competent in caring for a resident (Resident 1) who sustained an unwitnessed fall. LVN 1 did not conduct an initial assessment of Resident 1 following the fall, did not report the fall to Resident 1's physician, and failed to notify the Registered Nurse Supervisor (RNS 1) or Resident 1's Responsible Party (RP) about the incident. This lack of action resulted in Resident 1 experiencing significant pain without appropriate intervention or notification to relevant parties. Resident 1, who had a history of falls and a subdural hemorrhage, was found on the floor by a Certified Nursing Assistant (CNA 1) but was unable to explain how the fall occurred. Despite being in pain, as evidenced by screaming and guarding her left leg during a physical therapy evaluation, LVN 1 did not report these findings to the physician or RNS 1. The resident's RP discovered the pain during a visit and requested emergency medical assistance, which led to the administration of pain medication by paramedics. Interviews revealed that LVN 1 did not follow the facility's policy for notifying the physician and next of kin about changes in a resident's condition or incidents. Additionally, LVN 1 had not received in-service training on fall assessment and prevention, as the relevant training video was introduced after her hire date. The Director of Staff Development confirmed that fall education is conducted annually, but LVN 1 had not been updated with the new training materials.
Failure to Notify Resident's Representative of Transfer
Penalty
Summary
The facility failed to ensure that a resident and their responsible party were informed of the resident's transfer to another facility, violating the resident's right to make an informed decision regarding the transfer. The resident, who was admitted with diagnoses including dementia, cerebral infarction, and mental and behavioral disorders, had moderately impaired cognitive skills for daily decision-making. The resident's representative, who had previously been involved in decision-making processes such as informed consent for psychoactive medication treatment, was not notified of the transfer. Interviews and record reviews with facility staff, including an LVN, the Director of Staff Development, and the Director of Nursing, confirmed that there was no documentation indicating that the resident's representative was informed of the transfer. The facility's policy and procedure on charting and documentation required that family notification be documented, but this was not done in this case. The lack of notification was confirmed by multiple staff members, and the facility's policy was not adhered to, leading to the deficiency.
Failure to Prevent Unplanned Weight Loss in Resident
Penalty
Summary
The facility failed to prevent unplanned weight loss in a resident, who experienced a significant weight loss of 24.3 pounds, or 18.2%, over 40 days. This deficiency was due to the staff's failure to identify and report the resident's decrease in oral intake to the physician in a timely manner. The resident began refusing meals and consuming less food after being readmitted from a hospital stay, but the nursing staff did not notify the physician until 16 days later, contrary to the facility's policy and procedure. The resident, who had a history of metabolic encephalopathy, COPD, type II diabetes, and major depressive disorder, was at risk for malnutrition and dehydration due to the significant weight loss. Despite the Registered Dietician's recommendations to monitor the resident's weight and oral intake, the staff did not follow through with these recommendations. The resident's care plan, which required notifying the physician and dietician of meal refusals and significant weight loss, was not adhered to, leading to the resident's severe weight loss and the eventual need for a gastrostomy tube. The facility's failure to follow its own policies and procedures, including the lack of documentation and timely communication with the physician, contributed to the resident's decline. The Quality Assurance nurse and Director of Nursing acknowledged the oversight in not reporting the resident's poor oral intake and weight loss promptly, which could have allowed for earlier interventions to prevent the severe weight loss and subsequent medical complications.
Latest citations in California
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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