Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Astoria Healthcare Center during CMS and state inspections, most recent first.
Facility temperatures were below the stated acceptable range in multiple resident areas, including one resident room and a shared room for two residents. The MD measured temperatures as low as 66.1 F in a hallway and 68.4 F in a room, while residents reported feeling cold at night and needing extra blankets or a jacket. The DON acknowledged some areas were out of range and that the temperatures could affect resident comfort and psychosocial needs.
A resident with impaired cognition and documented inability to make medical decisions was given and signed a Notice to Beneficiary-change in coverage form and a NOMNC instead of having these notices provided to the appropriate representative. Staff stated the family member had requested coverage information, but the resident’s H&P and MDS showed limited decision-making capacity, and the DON and case manager confirmed the notices should have gone to the representative.
Incorrect Reconciliation of Anti-Cancer Medication on Readmission: A resident with metastatic melanoma was readmitted after hospitalization with orders for dabrafenib 150 mg PO BID, but the facility entered the order as 75 mg one capsule q12h and administered the lower dose for 20 days. The MAR, physician documentation, and SOAP notes did not align, and the ADON and DON confirmed the dose was entered incorrectly on readmission.
Failure to Ensure AP Completed Initial Visit: A resident admitted with malignant melanoma and pneumothorax had an H&P completed and electronically signed by the NP, with no documented evidence that the AP visited upon admission. The ADON confirmed the AP visit was not documented, and the DON stated the H&P should have been conducted by the AP. Facility policy states the initial comprehensive visit may not be performed by an NP, PA, or CNS employed by the facility.
Inaccurate Documentation of Family Notification Time: A resident’s nursing admission assessment incorrectly recorded that an RN notified a family member before the resident was admitted. The resident had diagnoses including malignant melanoma and pneumothorax, and both the ADON and DON confirmed the timing of the family notification was documented incorrectly.
Failure to Protect Resident from Abuse: Two residents had a physical and verbal altercation in the activity room, and one resident struck the other resident on the face while cursing. Staff interviews confirmed the incident as abuse. The affected resident had COPD, muscle weakness, and anxiety, while the other resident had chronic respiratory failure, delusional d/o, and generalized anxiety, with impaired cognition noted in the record.
The facility failed to properly document and account for controlled substances for two residents. One resident's lisdexamfetamine count on the narcotic record did not match the actual bubble pack count, and an LVN stated the dose had been given without being documented or signed for. For another resident, the DON reported a former LVN was terminated after repeated failures to document hydrocodone-acetaminophen administration on the EMAR.
A resident with dementia, aphasia, and a stroke history was documented as lacking capacity to understand and make decisions, yet the Consent to Treat Authorization showed the resident signed for consent. The AHCD named a family member as the HC agent, and family reported the resident should not have signed documents. The DON stated consent for residents without capacity should involve family contact, and that this was not done.
Failure to Monitor Anticoagulant Therapy: A resident with dementia, prior stroke sequelae, and bilateral DVT-related diagnoses was ordered Lovenox and later Eliquis for DVT PPX, with care plans directing staff to monitor for bleeding and other anticoagulant complications. The MARs for April and May showed the anticoagulant monitoring was not signed off as completed, and the DON confirmed the missing check-offs meant staff did not perform the required monitoring for bleeding.
Portable oxygen tanks were found standing in a resident's room without a secured rack or cart. The resident had COPD, chronic pulmonary edema, acute respiratory failure, dependence on supplemental O2, and severely impaired cognitive function. An LVN stated the tanks should be in a safe container to prevent falling, and the DON stated they should not be on the floor without a secured rack. The facility policy required oxygen cylinders to be secured in a cylinder cart or bracket at all times.
A resident with dementia, aphasia, and a history of falls had inaccurate charting after an unwitnessed fall: the fall risk assessment listed no prior falls and a lower risk score despite prior documentation showing high fall risk. Meal intake records were also inconsistent between the RNA dining meal percentage form and the Nutrition-Amount Eaten record, with mismatched percentages and one missing entry. The DON stated the fall assessment and meal documentation were inaccurate.
Failure to report resident-to-resident abuse allegation: A resident with impaired cognition and multiple chronic conditions reported that another resident pulled her hair, and staff members relayed the allegation to RN, DON, and ADM. A CNA also witnessed the other resident touch the resident's head. Although the ADM acknowledged the policy required immediate reporting of abuse allegations, the allegation was not reported to the SSA within the required timeframe.
Failure to Assess and Monitor Resident After Alleged Abuse: A resident with impaired cognition and multiple chronic conditions reported that another resident pulled her hair, and staff confirmed the allegation was relayed through nursing leadership. However, the RN/LVN documentation did not show a COC evaluation, MD notification, progress notes, or a care plan addressing the event, and social services did not complete the expected psychosocial visits after the incident.
Surveyors found that staff failed to follow contact isolation and infection control practices for two residents on precautions for C-diff. A CNA entered a contact isolation room without gown and gloves and placed a resident’s food tray on a cart with other residents’ trays. There were no dedicated linen hampers in the isolation rooms to separate soiled linens and clothing from those of other residents. A family member was observed visiting a resident on contact precautions without PPE and reported not being informed of the reason for isolation or required precautions, despite facility policies requiring staff to educate visitors and use appropriate PPE and linen handling procedures.
A resident with C.-diff, moderate cognitive impairment, and significant ADL assistance needs had almost daily visitors while on contact isolation, but the facility failed to provide and document infection control education for those visitors. Although staff were trained on appropriate PPE use, contact precautions, and the need for soap-and-water handwashing rather than alcohol-based sanitizer for C.-diff, record review showed no evidence that similar teaching was extended to visitors. This failure occurred despite a written infection prevention and control policy stating that infection control procedures apply equally to staff, residents, visitors, and others, and are intended to prevent, detect, investigate, and control infections.
A resident with metabolic encephalopathy, pneumonia, osteoporosis, a history of falls, and moderately impaired cognition had physician orders for continuous O2 at 2 L/min via nasal cannula with O2 saturation checks every nursing shift and physician notification below specified saturation thresholds. For five days, there was no documented shift-by-shift O2 saturation monitoring while the resident was ordered continuous oxygen, and part of the record showed the resident on room air. In addition, the admission fall risk assessment documented no fall history, only one diagnosis, and a weak gait, yielding a low fall risk score, despite other records showing a history of falls, multiple diagnoses, and impaired gait per facility criteria. The DON and LVN acknowledged that the O2 monitoring was not documented and that the fall risk score should have been higher based on the resident’s condition and facility policy.
A resident with diabetes, Alzheimer’s disease, and hypertension experienced a change of condition after an incident of physical aggression by another resident. A CNA reported the event to an LVN, who later completed a change-of-condition evaluation with the wrong date and shift for when the incident occurred. The LVN also documented incorrect times for when the MD and the resident’s family were notified, and could not recall the actual notification times. The evaluation was not completed and signed until two days after the event, contrary to facility policies requiring accurate, timely documentation and completion by the end of the assigned shift.
Surveyors found that three residents with existing sacral pressure ulcers or moderate risk for pressure ulcers, as indicated by Braden scores and MDS assessments, were not consistently turned and repositioned every two hours as required by their care plans. These residents had significant conditions such as Parkinson’s disease, diabetes, muscle weakness, and failure to thrive, and required maximal to moderate staff assistance or were fully dependent for rolling. Review of medical records with the TxN and confirmation by the DON showed no documentation that the ordered q2h repositioning was carried out, despite a facility pressure ulcer prevention policy requiring monitoring and documentation of prevention techniques.
A resident with Parkinson’s disease, type 2 DM, and a stage 4 sacral pressure ulcer experienced a change in condition with fever, SOB, and altered responsiveness and was transferred to a GACH, where the resident remained and was later discharged. Despite the resident no longer being in the facility, an LVN later documented that the resident was in bed, able to make needs known, free of SOB or acute distress, had received and tolerated all due meds, was kept clean and dry, and had specific vital signs recorded. During review, the DON confirmed the resident had already been transferred out at the time of this entry and that the documentation was inaccurate and not consistent with the facility’s nursing documentation policy.
A resident with end-stage renal disease and a history of removing her AV fistula dressing returned from hemodialysis and was not assessed or monitored as required by her care plan. Staff failed to inspect the access site or communicate the resident's return, resulting in the resident being found unresponsive and bleeding from the fistula site, leading to her death. Additionally, the facility did not promptly develop a care plan for another resident admitted to hospice, causing a delay in care planning.
A resident with ESRD, anemia, and a history of removing her own AV fistula dressing returned from hemodialysis and was not properly assessed or monitored by nursing staff. The RN did not inspect the access site or check vital signs, and no post-dialysis assessment was documented. The resident was later found unresponsive with severe bleeding from the AV fistula site and was pronounced deceased. Facility staff failed to follow established protocols for post-dialysis care and monitoring.
Nursing staff, including an RN and an LVN, did not receive orientation or in-service training on dialysis care or assessment, as confirmed by skills checklists, job descriptions, and staff interviews. The Director of Staff Development and the DON acknowledged that dialysis care was not part of the orientation process, and the facility's policy on staff competency was not followed for dialysis care. This resulted in staff lacking the necessary knowledge and skills to safely care for residents requiring dialysis.
The facility did not update its Facility Assessment Tool after a change of ownership and the implementation of electronic medical records, and failed to specify required staff training for dialysis care. The assessment continued to list the previous facility name and omitted details about electronic health information technology and dialysis competencies, resulting in outdated and incomplete documentation.
A resident's MDS assessment did not include a documented diagnosis of dementia, even though this was present in the primary physician's History and Physical. The MDS Coordinator relied on outdated admission records instead of reviewing current physician documentation, leading to an incomplete and inaccurate assessment.
A CNA did not change her gown after repositioning a resident with a gastrostomy and before draining another resident's Foley catheter, despite both requiring enhanced barrier precautions. This failure to follow infection control protocols was confirmed by the DON and had the potential for cross-contamination.
A resident with heart failure, atrial fibrillation, hypertension, chewing and swallowing difficulty, and a weight loss regimen had a care plan for monitoring meal intake and receiving the ordered diet. However, only one meal was documented on multiple days, and the MRD and DON confirmed there was no documentation that breakfast and lunch were provided or refused, despite policy requiring nursing staff to monitor meal acceptance and CNAs to document care by the end of the shift.
Failure to Obtain Signed and Dated Witness Statements for Resident Altercation: The facility failed to follow its abuse investigation policy after an altercation between two residents. Staff documented interviews instead of obtaining written, signed, and dated witness statements. One resident had metabolic encephalopathy, DM, and repeated falls with moderately impaired cognition and max assist needs, while the other had hemiplegia/hemiparesis after CVA with moderately impaired cognition and max assist needs. The DON stated the policy was not followed.
Failure to Address Refusal of Feeding Assistance in Care Plan: A resident with CHF, AFib, HTN, chewing and swallowing difficulty, and need for supervision with eating was observed eating pureed food on her own after refusing feeding assistance. CNAs and nursing staff were aware of the refusal, but the care plan did not address the resident’s refusal of feeding assistance or include related interventions, despite staff and the RD stating the resident needed assistance and supervision with meals.
A resident with heart failure, atrial fibrillation, and HTN received hydralazine despite a BP of 100/67 mmHg, even though the physician order required the medication to be held if systolic BP was below 110 mmHg or HR was below 60 bpm. The DSD and DON confirmed the LPN should have followed the order and held the medication.
A resident with cognitive impairment was involved in an incident where a family member attempted to have them sign a bank authorization form. Staff intervened and identified the situation as potential financial abuse, but the required five-day investigation report was not completed in accordance with facility policy.
A resident with multiple chronic conditions fell after attempting to steady herself on a wheelchair that was not within reach. Although staff assessed the resident and completed required documentation, there was no evidence that an IDT meeting was held within the facility's required timeframe to investigate the fall and address its causes, as mandated by facility policy.
A resident with multiple chronic conditions experienced a fall, and the required Post-Fall Assessment & Investigation was not completed or documented in the medical record as mandated by facility policy. Staff confirmed the omission, and review of the electronic record showed the assessment template was left incomplete, resulting in an incomplete medical record.
The facility did not ensure proper documentation and follow-up regarding advance directives for three residents. One resident's chart lacked evidence that advance directive information was provided, another had no copy of a living will in the chart despite acknowledging its existence, and a third resident's request for assistance in formulating an advance directive was not adequately followed up or documented by social services staff.
Multiple residents experienced deficiencies in their living environment, including an inaccurate wall clock for a resident with dementia, broken and unrepaired blinds with makeshift cardboard coverings for another, a torn fall mat with equipment placed on it for a resident at high risk for falls, and cracked or missing wall sockets at the bedside of a resident with severe impairments. Staff and maintenance were aware of these issues, but they were not addressed in accordance with facility policy, resulting in an environment that was not safe, clean, or homelike.
Multiple residents were subjected to physical restraints, such as bed pad alarms, bolstered mattresses, beds placed against walls, and side rails, without proper restraint assessments, physician orders, informed consent, or care plans. Staff confirmed that these interventions were implemented without following required protocols, and necessary documentation was only completed after the deficiencies were identified.
Two residents were administered psychotropic medications without proper diagnoses or monitoring. One received Seroquel without a qualifying mental health diagnosis, and pharmacy recommendations to discontinue the drug were not followed up or documented. The resident was also not referred for psychiatric evaluation as required. Another resident was prescribed Remeron for poor appetite related to depression, but staff failed to implement required monitoring for both the targeted behavior and medication side effects, as confirmed by nursing and DON interviews.
The facility did not develop or implement comprehensive care plans for multiple residents, including those who smoked, received psychotropic or antianxiety medications, or required BiPAP therapy. This included missing care plans for smoking safety, medication monitoring, and respiratory equipment care, as well as incomplete documentation and communication among staff regarding residents' needs and interventions.
Three residents did not have their care plans updated to reflect current infection control precautions or the use of low air loss mattresses for pressure ulcer prevention. Staff interviews and observations confirmed that care plans were not revised after changes in physician orders or resident condition, and that mattress settings did not match residents' weights as required. These deficiencies led to potential miscommunication and delays in necessary care.
Two residents receiving subcutaneous insulin did not have their injection sites rotated as required by physician orders, facility policy, and manufacturer guidelines. Nursing staff repeatedly administered insulin in the same abdominal and arm locations over an extended period, a practice confirmed by both nursing staff and the DON through record review and interviews.
Multiple deficiencies were identified when medications and hazardous materials were left unattended in resident rooms, topical medications were applied without proper orders, and safety equipment such as floor mats and bed positions were not properly maintained. Staff failed to follow facility policies, resulting in increased risk of accidents and injuries for several residents with complex medical needs.
Several residents requiring respiratory support did not receive care in accordance with professional standards, as BiPAP masks and nebulizer equipment were improperly stored, not cleaned or documented per manufacturer and facility policy, and oxygen tubing and masks were not labeled with the date of last change. Staff interviews confirmed inconsistent cleaning and documentation practices, and facility policies for infection control and equipment maintenance were not followed.
Multiple deficiencies were identified in the facility's pharmaceutical services, including failure to administer medications as ordered, administration of expired medications, late medication administration, incomplete documentation of discarded medications, and improper supervision of medication administration. These issues involved several residents with various medical conditions and were confirmed through staff interviews, record reviews, and direct observation.
Two residents receiving subcutaneous insulin did not have their injection sites rotated as required by physician orders, manufacturer guidelines, and facility policy. Nursing staff and the DON confirmed that insulin was repeatedly administered in the same areas, which was identified as a medication error according to facility policy and professional standards.
Surveyors found two unlabeled vials of meropenem in an IV cart after a resident's treatment was completed, and expired psyllium and docusate sodium in a medication cart. Nursing staff and leadership confirmed that these medications should have been discarded according to facility policy, but they remained accessible in storage areas.
Surveyors found that pureed mixed vegetables served to residents on a dysphagia puree diet were too thick and did not pass the required IDDSI Level 4 spoon tilt test. Staff did not consistently use the correct testing method to ensure proper food texture, and the Dietary Director confirmed the deficiency. Facility policies and recipes required these tests to be performed, but they were not followed, resulting in improper food consistency for all residents on a puree diet.
Surveyors found that kitchen staff failed to properly dispose of expired food, label and date various food items, and maintain sanitary storage and preparation practices. Observations included unlabeled produce, improperly stored thickener, mixed food items in bins, and unclean equipment. The dietary director confirmed that these actions did not follow facility policies for food safety and infection control.
Surveyors identified multiple failures in infection prevention and control, including lack of Enhanced Barrier Precautions for a resident with a history of VRE, improper disinfection of a cloth gait belt between residents, unclean supplement bottles on medication carts, staff not wearing or securing gowns during high-contact care, linen carts inadequately protected from dust, and improper storage and documentation of respiratory equipment. These deficiencies were confirmed through staff interviews, observations, and policy reviews.
Facility staff used the PT gym's therapy mat and surrounding area to store therapy equipment, broken items, and items awaiting disposal, making the space unavailable for resident therapy. The DOR and DON acknowledged that the cluttered environment prevented use of the therapy area for its intended purpose and did not meet expectations for a homelike, orderly setting.
Surveyors found that essential equipment was not maintained in safe working order, including a non-functional freezer light in the kitchen, a resident's bed controller with exposed wires, and cracked or missing wall sockets at the head of another resident's bed. Staff failed to report these hazards as required by facility policy, resulting in unsafe conditions for two residents with significant medical needs.
A CNA assisted a resident with severe cognitive impairment and total dependence for ADLs by standing over them during mealtime, rather than sitting at eye level as required by facility policy. Both the RN and DON confirmed that this practice did not uphold the resident's dignity, and facility policies specifically prohibit standing over residents while feeding.
Facility Failed to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain a comfortable and safe temperature level for three sampled residents by not keeping room and hallway temperatures within the stated acceptable range. Resident 19 was admitted with paraplegia, COPD, and essential hypertension, and his MDS dated 6/6/2026 indicated moderately impaired cognitive skills. During a concurrent observation and interview, the Maintenance Director measured Resident 19’s room at 70.2 F at bed level, hallway 1 at 67.5 F, and hallway 2 at 70 F. Resident 19 stated the room was cold at night, required an extra blanket, and sometimes made the resident uncomfortable. Resident 20 was admitted with type 2 diabetes mellitus, anxiety disorder, and anemia, and Resident 21 was admitted with unilateral primary osteoarthritis, anxiety disorder, and essential hypertension; both residents’ MDS assessments indicated intact cognitive skills. During a concurrent observation and interview, the Maintenance Director measured the shared room for Residents 20 and 21 at 68.4 F at bed level and hallway 3 at 66.1 F. Resident 20 stated the room was cold at night and required two extra blankets and a jacket, and Resident 21 stated the facility could make the room warmer at night. The Maintenance Director later stated the acceptable facility temperature should be between 70 F and 81 F, and the DON stated the facility temperature should be between 71 F and 81 F and acknowledged that some areas were out of range.
Failure to Obtain Proper Representative Signatures for Coverage Notices
Penalty
Summary
The facility failed to protect one resident’s right to make an informed decision by obtaining the resident’s signature on a Notice to Beneficiary-Change in Health Care Coverage form even though the resident was documented as unable to make medical decisions. The resident was admitted with diagnoses including anxiety disorder, schizophrenia unspecified, and a personal history of suicidal behavior. The History and Physical stated the resident could make needs known but could not make medical decisions and had poor insight and understanding into the medical condition, and the MDS described moderately impaired cognitive functioning. For the change in health care coverage form, the resident’s family member told staff she had not discussed or requested assistance with the resident’s coverage change. The admission coordinator assistant stated the family member had asked for information on coverage options and told staff the resident could make decisions, so the resident was given education and a phone number to call to change coverage. The form was then signed by the resident, even though the administrator stated the form should have been provided to the appropriate responsible party because the resident did not have capacity to make medical decisions. The facility also failed to provide the resident’s Notice of Medicare Non-Coverage form to the resident’s representative. The case manager stated the form was used to notify residents that coverage would end and to inform them of appeal rights, and stated the resident did not have capacity to make health care decisions and should have had the form provided to the representative. The DON stated the resident did not have capacity to participate in the appeal process and that the facility failed to provide the NOMNC to the family member, contrary to the facility’s resident rights policy requiring residents to be fully informed and participate in treatment in a language they can understand.
Incorrect Reconciliation of Anti-Cancer Medication on Readmission
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to accurately reconcile dabrafenib for one resident on readmission. The resident had diagnoses that included malignant melanoma with metastatic disease, and the hospital history and physical documented ongoing targeted oncology therapy with dabrafenib and trametinib. The hospital discharge information and physician documentation indicated dabrafenib 150 mg by mouth twice a day, but the facility’s readmission order entered on 4/1/2026 listed dabrafenib mesylate 75 mg, one capsule by mouth every 12 hours. The medication administration record showed the resident received dabrafenib 75 mg two capsules twice daily from 3/16/2026 through 3/28/2026 before transfer to the hospital, but after readmission the MAR showed dabrafenib 75 mg one capsule by mouth from 4/2/2026 through 4/22/2026. The resident’s SOAP notes on 4/3/2026, 4/7/2026, 4/11/2026, 4/14/2026, and 4/21/2026 continued to document dabrafenib 150 mg by mouth twice a day, which did not match the facility’s entered order. The resident’s cognitive skills for daily decisions were intact. During interviews, the family member stated the facility did not administer the correct dose of the anti-cancer medication and only gave one pill instead of two. The ADON stated the discharge summary indicated dabrafenib 75 mg two capsules every 12 hours, but the facility’s readmission order listed only one capsule every 12 hours, and the medication should still have been two capsules every 12 hours. The DON stated the nurse entered the dose incorrectly on readmission and that the resident received less than the ordered dose for 20 days.
Failure to Ensure AP Performed Initial Comprehensive Visit
Penalty
Summary
The facility failed to ensure that the Attending Physician performed the required comprehensive visit before allowing the Nurse Practitioner to complete the visit for one sampled resident. Resident 1 was admitted on 3/16/2026 with diagnoses including unspecified malignant melanoma of skin and unspecified pneumothorax. The admission record showed the resident was admitted at 8:30 p.m., and the nursing admission assessment documented the admission date. The History and Physical for Resident 1, dated 3/16/2026, indicated the resident had the capacity to understand and make decisions, and the Minimum Data Set dated 4/7/2026 indicated the resident’s cognitive skills for daily decisions were intact. During interview, the ADON stated the History and Physical was done by the NP and that there was no documented evidence in the medical record that the AP came and visited Resident 1 upon admission. The DON stated the History and Physical should be conducted by the AP so the resident could be assessed thoroughly and the initial care plan could be developed. The facility policy titled Physician Services and Visits stated that initial comprehensive visits may not be performed by the PA, NP, or CNS employed by the facility.
Inaccurate Documentation of Family Notification Time
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one sampled resident by incorrectly documenting the time a family member was notified of the resident’s admission. Resident 1 was admitted on 3/16/2026 with diagnoses including unspecified malignant melanoma of skin and unspecified pneumothorax. The nursing admission assessment, dated 3/16/2026, documented that RN 1 notified Family Member 1 at 12 midnight, which was recorded as occurring before the resident was admitted to the facility at 8:30 p.m. that same day. Resident 1’s H&P dated 3/16/2026 indicated the resident had capacity to understand and make decisions, and the MDS dated 4/7/2026 indicated the resident’s cognitive skills for daily decisions were intact. During interview and record review, the ADON stated the facility’s process was to inform family after admission and confirmed RN 1 made incorrect documentation of the time of notification. The DON also stated RN 1 incorrectly documented the timing of family notification and that assessment documentation should be accurate to show no laps in care.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from abuse when two residents had a physical and verbal altercation in the activity room, and one resident hit the left side of the other resident’s face. The incident occurred during coffee hour in the morning, and staff later documented it as an alleged physical aggression toward the resident. The report states that this deficient practice denied the resident a safe, harm-free, homelike environment where the resident was not exposed to danger or emotional distress. Resident 1’s record showed diagnoses of COPD, muscle weakness, and anxiety disorder. A history and physical examination noted that Resident 1 could make needs known but could not make medical decisions. The MDS indicated intact cognitive functioning, but the resident required substantial to maximal assistance with toileting, showering/bathing, and lower body dressing. A change in condition evaluation documented that Resident 1 was allegedly hit on the left side of the face and back of the head. Resident 2’s record showed diagnoses of chronic respiratory failure, delusional disorders, and generalized anxiety disorder. A history and physical examination indicated Resident 2 had the capacity to understand and make decisions, while the MDS showed moderately impaired cognitive function and partial to moderate assistance needs for toileting, showering/bathing, and upper body dressing. The physician ordered transfer of Resident 2 to a GACH via 5150 for evaluation. Staff interviews confirmed that Resident 2 struck Resident 1 and used cursing during the incident, and the facility policy stated that residents have the right to be free from abuse and that the facility has zero tolerance for abuse.
Controlled Substance Documentation and Count Errors
Penalty
Summary
The facility failed to maintain a system-wide method for the management and accounting of controlled substances for two sampled residents. For one resident, the record showed an order for lisdexamfetamine dimesylate 30 mg daily for binge eating disorder. During an observation of the medication cart and controlled substance binder, one capsule was missing from the bubble pack and 14 capsules remained, while the Narcotic and Hypnotic Record still showed 15 capsules remaining. An LVN stated the count should have been 14 capsules and acknowledged that the medication had not been documented or signed for when it was given. For another resident, the record showed an order for hydrocodone-acetaminophen 5-325 mg, one tablet each morning for pain management. During interview and record review, the DON stated a former LVN had been terminated for medication administration errors because she was not documenting on the EMAR when she dispensed a narcotic. The DON stated the first warning occurred after one incident and a second incident occurred a few days later, with both incidents affecting this resident's file. The residents involved had significant medical conditions and functional limitations. One resident had diagnoses including polyneuropathy, morbid obesity, and binge eating disorder, and was documented as having intact cognitive functioning and needing assistance with toileting, bathing, and lower body dressing. The other resident had diagnoses including anoxic brain damage, epilepsy, and type 2 diabetes mellitus, was documented as unable to make medical decisions, had severely impaired cognition, and required assistance with toileting, bathing, and upper body dressing.
Improper Consent Obtained From Resident Without Capacity
Penalty
Summary
The facility failed to ensure that a resident who lacked the capacity to understand and make decisions was not made to sign the Consent to Treat Authorization. The resident was admitted with diagnoses including dementia, unspecified sequelae of cerebral infarction, and aphasia. The resident’s H&P note stated the resident did not have the capacity to understand and make decisions, and the AHCD identified Family Member 2 as the resident’s Health Care Agent. Despite this, the Consent to Treat Authorization dated 4/7/2026 indicated the resident signed the consent. During interview, Family Member 1 stated the resident’s power of attorney was Family Member 2, that Family Member 2 was not present because they do not drive, and that the facility had the resident sign documents even though the resident was admitted with dementia and unable to sign for himself. Family Member 1 stated she complained to the facility and that the facility had her sign next to the resident’s name. The DON stated consent to treat is obtained by the nurse at bedside, that residents without capacity require family contact, and that if residents sign without capacity, the facility is violating resident rights. The DON also stated the proper process was not followed for this resident.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure proper monitoring for bleeding and other anticoagulant complications for a resident who was admitted with dementia, prior cerebral infarction sequelae, chronic embolism and thrombosis of bilateral lower extremity deep veins, and aphasia. The resident’s history and physical stated the resident did not have the capacity to understand and make decisions. On admission, the resident was ordered Lovenox 40 mg subcutaneously every 24 hours for DVT prophylaxis, and the care plan directed staff to administer anticoagulant therapy as ordered and monitor, document, and report signs and symptoms of anticoagulant complications, including blood in urine or stool, bruising, sudden severe headache, nausea, vomiting, lethargy, shortness of breath, and changes in mental status or vital signs. The resident’s care plan later included anticoagulant therapy for Eliquis and continued the same monitoring expectations. The MDS showed the resident was usually understood, sometimes able to understand, and required varying levels of assistance with toileting, bathing, dressing, hygiene, and eating. The resident’s MAR for April 2026 and May 2026 included anticoagulant monitoring orders, but the monitoring was not signed off as completed by nursing staff. The record also showed a physician order on 5/5/2026 for Eliquis 2.5 mg by mouth twice daily for 35 days for DVT prophylaxis related to chronic embolism and thrombosis of bilateral lower extremity deep veins. During interview and record review, the DON stated anticoagulant medication should be monitored specifically for bleeding and that the lack of check-off indicated staff did not perform the monitoring. The DON further stated that if staff do not monitor, they will not know if there are bleeding complications. The facility policy on anticoagulant therapy stated anticoagulant therapy is to be safely and effectively administered and that residents receiving anticoagulant therapy will be monitored.
Portable oxygen tanks left unsecured in resident room
Penalty
Summary
The facility failed to ensure portable oxygen tanks for one resident were properly stored securely to prevent them from falling. The resident was admitted with diagnoses including COPD with acute exacerbation, chronic pulmonary edema, acute respiratory failure, and dependence on supplemental oxygen. The resident's MDS dated 3/12/2026 indicated severely impaired cognitive function, and the order summary dated 4/7/2026 directed oxygen at 2 liters per minute via nasal cannula with humidification continuously every shift related to COPD to maintain oxygen saturations greater than 91 percent. During a concurrent observation and interview on 5/11/2026 at 12:12 p.m., two portable oxygen tanks were observed standing in the corner of the resident's room without a secured rack or cart. The LVN stated the oxygen tanks should not be stored in the resident's room and should be placed in a safe container to prevent them from falling. During an interview later that day, the DON stated portable oxygen tanks are stored in an oxygen container but should be in the storage room, and that they should not be on the floor without a secured rack. The facility's policy titled Oxygen Administration, last reviewed on 1/15/2026, stated oxygen cylinders are to be secured in a cylinder cart or bracket at all times.
Inaccurate fall risk and meal intake documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards for one resident when documentation related to a fall and meal intake was inaccurate. The resident was admitted with diagnoses including dementia, sequelae of cerebral infarction, chronic embolism and thrombosis of the lower extremities, and aphasia. The history and physical note stated the resident did not have the capacity to understand and make decisions, and the nursing admission assessment documented a history of falling with a fall risk score of 75, indicating high fall risk. After an unwitnessed fall, the resident’s change in condition evaluation was completed, but the fall risk assessment documented no prior history of falling and assigned a score of 40, which was inconsistent with the resident’s prior assessment and history. The DON reviewed the assessment and stated it should have indicated a history of falls, that the score was inaccurate, and that the initial score of 75 reflected high fall risk. The DON also stated the inaccurate score could affect the plan of care and that interventions might not match the resident’s needs. The resident’s meal documentation was also inconsistent between two facility forms. The RNA dining meal percentage and the Nutrition-Amount Eaten record did not match for several meals, including entries where one form showed the resident ate 80%, 100%, 90%, or 100%, while the other form showed 26% to 50%, no percentage documented, or 51% to 75%. RNA staff stated the two documents did not match and explained that RNAs documented the dining meal percentage while CNAs documented Nutrition-Amount Eaten. The DON reviewed the records and stated the amounts eaten should correlate and that the documentation was inaccurate. The facility policy stated documentation should be concise, clear, pertinent, and accurate.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident physical abuse to the State Survey Agency after a resident reported that another resident pulled her hair. The resident involved had a history of type 2 diabetes mellitus, diastolic congestive heart failure, and essential hypertension, and her H&P stated she did not have the capacity to understand and make decisions; her MDS also indicated moderately impaired cognitive skills for daily decision making. During interviews, the resident stated the other resident pulled her hair and that licensed nursing staff assessed her after the incident, while LVN 1 stated the allegation was reported to RN 1, the DON, and the ADM after the resident reported it the following morning. RN 1 stated she was informed of the allegation and sent a text message to the DON and ADM, but the allegation was not reported to the SSA. CNA 6 stated he witnessed the other resident touch the resident's back of the head and reported it to LVN 5, who then reported it to RN 1. The DON stated he was told that the other resident touched the resident's hair, did not ask the resident whether her hair had been pulled, and acknowledged the allegation was not reported to the SSA. The ADM, who stated he was the facility's Abuse Coordinator, reviewed the facility policy requiring allegations of abuse to be reported immediately, but no later than two hours after forming suspicion, and acknowledged the facility failed to report the allegation within two hours.
Failure to Assess and Monitor Resident After Alleged Abuse
Penalty
Summary
The facility failed to follow professional standards of nursing practice for one resident after a change of condition related to an alleged physical abuse incident. The resident had been admitted with diagnoses including type 2 diabetes mellitus, diastolic congestive heart failure, and essential hypertension, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated the resident’s cognitive skills for daily decision making were moderately impaired. According to the record and interviews, the resident reported that another resident pulled her hair, and a CNA stated he witnessed the other resident touch the back of the resident’s head in the hallway. The CNA reported the incident to an LVN, who then reported it to an RN supervisor. The resident stated she told a licensed nurse the following morning, and staff interviews confirmed the allegation was discussed among nursing staff and the DON. The record review and staff interviews showed there was no documented evidence of a COC evaluation, physician notification, progress notes addressing the allegation, or a care plan reflecting monitoring and interventions after the incident. The LVN stated the resident should have been monitored every shift for 72 hours after the change of condition, and the SSD stated the resident should have received psychosocial visits from social services every day for three days following the change of condition, but these visits did not occur. The DON stated resident care not documented was considered not provided and acknowledged the facility failed to identify, document, and monitor the resident’s change of condition.
Failure to Follow Contact Isolation and Visitor Education Practices for Residents with C-diff
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program and contact isolation policies for two residents on contact precautions for Clostridium difficile (C-diff). Surveyors observed Certified Nursing Assistant (CNA) 1 enter the shared contact isolation room of Resident 1 and Resident 2 without wearing a gown and gloves, despite facility policy requiring these PPE items when entering contact isolation rooms. CNA 1 then removed Resident 1’s food tray from the isolation room and placed it on a cart with other residents’ food trays outside the room. Licensed Vocational Nurse (LVN) 1 stated that CNA 1’s actions went against facility policy and that entering a contact isolation room without appropriate PPE was not in accordance with the contact precautions protocol. The surveyors also observed that there were no designated linen carts or dedicated hampers for soiled linens and clothes in the contact isolation rooms for Resident 1 and Resident 2, even though the Infection Preventionist (IP) Nurse acknowledged that residents with C-diff were supposed to have their own red hamper to separate their linens from those of other residents. The facility’s policy on Resident Isolation-Category of Transmission stated that used linen soiled with blood, body fluids, secretions, and excretions must be handled in a manner that prevents contamination and transfer of microorganisms to other residents and the environment. During a tour of three rooms on contact precautions for C-diff, this lack of dedicated linen containers was consistently observed. In addition, the facility failed to educate a family member on required precautions when visiting a resident on contact isolation. Surveyors observed Family Member 1 inside Resident 1’s contact isolation room without wearing a gown or gloves. Family Member 1 reported not being informed why the resident was in contact isolation or what precautions to take while visiting. The Director of Nursing (DON) confirmed that Resident 1 and Resident 2 were on contact isolation for C-diff and that facility policy required staff to educate family members visiting residents in contact isolation rooms. The DON also stated that the purpose of the infection prevention and control and visitation policies was to prevent the spread of infection and to make visitors aware of the risk of exposure to communicable diseases. Resident 1’s records showed admission and readmission with diagnoses including C-diff, gout, and dementia, with the Minimum Data Set indicating impaired cognitive skills and total dependence on staff for mobility, transfers, dressing, toileting, personal hygiene, and bathing. Resident 2’s records showed admission with diagnoses including rheumatic multiple valve disease, bacteremia, and acute respiratory failure with hypoxia. Both residents were confirmed by the DON to be on contact isolation precautions for C-diff at the time of the observations.
Failure to Educate Visitors on C.-diff Isolation Precautions and Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policy for a resident diagnosed with Clostridioides difficile (C.-diff). The resident was originally admitted with acute respiratory failure with hypoxia, pneumonia, and a cognitive communication deficit, and had moderate cognitive impairment per the MDS, requiring substantial/maximal assistance with toileting, bathing, and lower body dressing. A physician’s order directed staff to collect stool for C.-diff if diarrhea occurred, and the resident was confirmed positive for C.-diff on 4/18/2026. The facility’s Infection Prevention Nurse stated that for C.-diff, training was provided to licensed nurses and direct care staff on proper PPE use and handwashing, and acknowledged that a visitor was present with the resident daily and that it was important to inform visitors about PPE and handwashing after being in the resident’s room. A registered nurse reported receiving training on proper PPE use for contact isolation, including disposable gowns, gloves, and handwashing for at least 20 seconds, and stated that visitors and family are always educated on PPE use and hand hygiene, with specific emphasis that alcohol-based hand sanitizer is not effective for C.-diff. However, during review of the resident’s records with this nurse, there was no documentation of infection control teaching provided to visitors, despite the resident having almost daily visitors. The nurse identified the failure as a lack of education to the visitor regarding isolation precautions and the absence of documentation that such teaching was provided. The facility’s written Infection Prevention and Control Program policy states that infection control policies and procedures apply equally to all staff, consultants, contractors, residents, visitors, volunteer workers, and the general public, and are intended to prevent, detect, investigate, and control infections and maintain a safe and comfortable environment for personnel, residents, visitors, and the general public.
Failure to Monitor Oxygen Saturation and Accurately Assess Fall Risk
Penalty
Summary
The facility failed to follow professional standards of nursing practice for a resident who had been admitted with diagnoses including metabolic encephalopathy, pneumonia, age-related osteoporosis, and a documented history of falling. The resident’s MDS showed moderately impaired cognitive skills for daily decision making. Physician orders dated 3/14/2026 and 3/15/2026 directed continuous oxygen at 2 L/min via nasal cannula and required that the resident’s oxygen saturation be monitored every nursing shift, with instructions to notify the physician if saturation fell below specified thresholds. However, review of the medical record with an LVN and the DON showed no documented evidence that oxygen saturation was monitored every shift from 3/14/2026 to 3/19/2026, and an Oxygen Saturation Summary for part of that period indicated the resident was on room air. The LVN confirmed that there was no documentation of oxygen saturation monitoring for five days while the resident was ordered to receive continuous oxygen therapy. The DON stated that oxygen is considered a medication requiring a physician order and that oxygen saturation should be monitored and documented every shift according to those orders, further acknowledging that monitoring not documented is considered not done. Facility policies on Oxygen Administration required documentation of oxygen saturation levels as indicated and the patient’s response to oxygen therapy, but the resident’s record did not contain the required shift-by-shift monitoring entries for the specified period. The facility also failed to accurately assess the resident’s fall risk following readmission. The Nursing Admission Assessment dated 3/14/2026 documented that the resident had no history of falls, only one diagnosis, and a weak gait, resulting in a Fall Risk Assessment score of 10, which indicated low risk for falls. This conflicted with the Face Sheet, which listed a history of falling, and with the LVN’s statement that the resident had more than one diagnosis and an impaired gait as defined by the facility’s fall risk criteria. The DON agreed that the resident’s fall risk score should have been higher based on the assessment criteria. The facility’s Fall Management Program policy required licensed nurses to assess each resident’s fall risk upon admission, quarterly, and with significant change in condition, and to use that information to identify and implement interventions, but the inaccurate assessment led to an incorrect fall risk score for this resident.
Inaccurate and Delayed Change-of-Condition Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate, complete, and timely medical record for one resident who experienced a change of condition related to an incident of physical aggression by another resident. The resident had been admitted with diagnoses including type 2 diabetes mellitus, Alzheimer’s disease, and essential hypertension, and had severely impaired cognitive skills for daily decision-making per the most recent MDS. A CNA reported that another resident attempted to hit this resident on the evening of 3/9/2026, and an LVN responded to the incident. The LVN later created a Change of Condition (COC) Evaluation but documented the COC as occurring on 3/10/2026 during the night shift instead of on 3/9/2026 during the 3 p.m. to 11 p.m. shift when the incident actually occurred. The COC Evaluation also contained inaccurate information regarding the timing of notifications to the resident’s attending physician and family member. The form indicated that the physician was notified at 9:20 p.m. and the family member at 9:15 p.m. on 3/10/2026, while the LVN stated that both were notified after midnight on 3/10/2026 but could not recall the exact times. The LVN acknowledged that the COC Evaluation was inaccurate. The Assistant DON confirmed that the resident’s change in condition occurred on 3/9/2026, that the COC Evaluation was not completed and signed until 3/11/2026, and that facility policy required documentation of the correct date and time of the incident and notifications, with nursing documentation to be completed by the end of the assigned shift. These findings showed that the facility did not follow its own policies on change of condition notification and nursing documentation, resulting in inaccurate and untimely entries in the resident’s medical record.
Failure to Reposition Residents at Risk for Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards by not ensuring that three residents at moderate risk for pressure ulcers were turned and repositioned as care planned. One resident was admitted with Parkinson’s disease, type 2 diabetes mellitus, and a stage 4 sacral pressure ulcer, and had a Braden score of 13 indicating moderate risk. The resident’s MDS showed moderately impaired cognition and a need for maximal assistance with rolling. The resident’s care plan, initiated shortly after admission, required assistance with turning and repositioning at least every two hours, but the treatment nurse and the DON both confirmed there was no documented evidence that this turning and repositioning occurred every two hours as ordered. Another resident was admitted with a stage 4 sacral pressure ulcer, muscle weakness, and adult failure to thrive, and had a Braden score of 13, also indicating moderate risk. This resident’s MDS showed severely impaired cognitive skills and total dependence on staff for rolling to either side. The interdisciplinary wound management care plan directed staff to reposition the resident every two hours or as often as necessary. During record review with the treatment nurse, it was determined there was no documented evidence that the resident was turned and repositioned every two hours, despite the care plan intervention and the resident’s dependence on staff for mobility. A third resident, admitted with type 2 diabetes mellitus, muscle weakness, and essential hypertension, had a Braden score of 14, indicating moderate risk, and required moderate assistance with rolling according to the MDS. This resident also had a sacrococcygeal pressure ulcer and an interdisciplinary wound management care plan that required repositioning every two hours or as often as indicated. The treatment nurse and the DON confirmed there was no documented evidence that this resident was turned and repositioned every two hours. The facility’s pressure ulcer prevention policy required nursing staff to monitor interventions for effectiveness and for licensed nurses to document the effectiveness of pressure ulcer prevention techniques weekly, but the lack of documentation of turning and repositioning for all three residents demonstrated that these interventions were not implemented as required.
Inaccurate Nursing Documentation Entered After Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with accepted professional standards for one resident. The resident was admitted with Parkinson’s disease, type 2 diabetes mellitus, and a stage 4 sacral pressure ulcer, and had moderately impaired cognitive skills for daily decision-making per the MDS. A Change in Condition evaluation documented that the resident developed fever, shortness of breath, and a sudden change in level of consciousness or responsiveness. Progress notes show that on 12/10/2025 at 10:10 a.m., the resident was transferred to a general acute care hospital and did not return, ultimately being discharged from the hospital. Despite the resident’s transfer and non-return, a progress note dated 12/13/2025 was entered by an LVN documenting that she received the resident resting in bed, able to make needs known, being monitored for fever, congestion, and lethargy, with no shortness of breath or acute distress, no pain, all medications given and tolerated, and that the resident was kept clean and dry with call light within reach. The note also included specific vital signs (blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation) as if the resident were present in the facility. During interview and concurrent record review, the DON confirmed that the resident had been transferred out on 12/10/2025, did not return, and that the LVN’s 12/13/2025 documentation was inaccurate and not in accordance with the facility’s nursing documentation policy, which requires concise, clear, pertinent, and accurate documentation of resident status and care given.
Failure to Implement Hemodialysis Care Plan and Timely Hospice Care Planning
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with end-stage renal disease who required hemodialysis and had a left upper arm arteriovenous (AV) fistula. The resident had a documented history of removing her pressure dressing prematurely after dialysis, resulting in previous bleeding episodes. Despite care plan interventions specifying that the dressing should remain in place for at least four hours post-dialysis and that the access site should be monitored for bleeding, redness, swelling, and pain upon return from dialysis, staff did not perform or document a post-dialysis assessment or direct inspection of the AV fistula site after the resident returned from treatment. The resident was also on Eliquis, an anticoagulant, further increasing her risk for bleeding. On the day of the incident, the resident returned from hemodialysis and was assisted to her room by an RN, who did not visually inspect the AV fistula site or check vital signs, assuming the site was not bleeding because the clothing was not wet. The RN did not inform other staff of the resident's return, and both the assigned LVN and CNA were on lunch breaks and unaware of the resident's status. Approximately 30 minutes later, the CNA discovered the resident unresponsive and actively bleeding from the AV fistula site, with the pressure dressing removed and blood present on the bed and floor. Emergency services were called, but the resident was pronounced deceased shortly after their arrival. Interviews and record reviews confirmed that the required post-dialysis assessment was not completed, and there was no documentation of monitoring or care provided to the AV fistula site upon the resident's return. The care plan interventions related to hemodialysis and AV fistula monitoring were not implemented, and staff failed to communicate and coordinate care as required. Additionally, the facility failed to promptly develop and implement a person-centered care plan for another resident admitted to hospice, resulting in a delay in care planning.
Removal Plan
- The DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment, including interviews with assigned nursing staff, review of policy and procedure on Dialysis Care, forms used for dialysis care, nurses progress notes, and communication related to Resident 1's return from dialysis. Failures related to post-dialysis assessment, monitoring, communication, and documentation were identified.
- All residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse and/or RN. The assessment will include direct inspection of the hemodialysis access site, vital signs, bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. The CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN.
- The RN Supervisor and Charge Nurse reviewed and updated the person-centered care plans for residents receiving hemodialysis (Residents 2, 3, 4, 5, 6, 7, 8, and 9) to reflect each resident's individual needs and the required care of their dialysis access sites.
- The DON and Medical Records staff conducted an audit on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents (Residents 2, 3, 4, 5, 6, 7, 8, 9) receiving hemodialysis treatment. There were no other residents identified with deficiencies similar to those found for Resident 1.
- The DON and RN Supervisor conducted an audit of care plans related to dialysis care and the Nursing Facility Post Dialysis Assessment form for eight residents (Resident 2, 3, 4, 5, 6, 7, 8, and 9) receiving hemodialysis. The audit showed that all applicable care plan interventions were present and up to date for Residents 2, 3, 4, 5, 6, 7, 8, and 9.
- The DON and DSD provided in-service training to nursing staff regarding care planning, with emphasis on: a) Implementation of residents' individualized hemodialysis care plans; b) Completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment and nursing progress notes documenting the date and time residents returned to the facility, to be completed by LVNs or RNs following hemodialysis treatment; c) Comprehensive assessment and monitoring of residents by LVNs or RNs following dialysis treatment.
- The DON provided a one on one in-service to RN 1 and LVN 1, who were assigned to Resident 1 during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care. The in-service addressed conducting pre and post dialysis assessments with focus on assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications. The in-service addressed documentation on the nurse's progress notes and the Nursing Facility Pre and Post Dialysis Assessment form. Licensed nurse will document in the nurse's progress notes resident's return to the facility from the hemodialysis treatment, including the date and time of the return and the care provided to the resident.
Failure to Assess and Monitor Dialysis Resident Post-Treatment Resulting in Fatal Hemorrhage
Penalty
Summary
A deficiency occurred when a resident with end-stage renal disease, anemia, atrial fibrillation, and a history of removing her own dialysis access site dressing was not properly assessed or monitored upon return from an outpatient hemodialysis treatment. The resident was prescribed Eliquis, increasing her risk for bleeding, and had documented prior incidents of prematurely removing her AV fistula dressing, resulting in bleeding. Despite these known risks and care plan interventions requiring monitoring of the access site and leaving the dressing in place for at least four hours post-dialysis, staff failed to conduct a post-dialysis assessment or monitor the resident for complications upon her return. On the day of the incident, the resident returned to the facility at approximately 7:10 p.m. after hemodialysis. The assigned RN assisted the resident to her room but did not visually inspect the AV fistula site, check vital signs, or document the resident's return. The RN assumed the site was not bleeding because the resident's clothing was not wet and did not notify other staff of the resident's return. Both the LVN and CNA assigned to the resident were on their lunch breaks and were not informed of the resident's return. No staff member was designated to receive or assess the resident upon her arrival, and there was no documentation of a post-dialysis assessment in the medical record. Approximately 40 minutes later, the CNA discovered the resident unresponsive, with the AV fistula dressing removed and active bleeding from the site. Blood was found on the bed, floor, and the resident's clothing. Emergency measures were initiated, but the resident was pronounced deceased by paramedics. Interviews and record reviews confirmed that facility staff did not follow established policies and procedures for post-dialysis assessment, monitoring, and documentation, nor did they implement the resident's care plan interventions for AV fistula care and monitoring.
Removal Plan
- The DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment, including interviews with RN 1 and LVN 1, review of facility's P&P on Dialysis Care, forms used for dialysis care, nurses progress notes, and communication related to Resident 1's return from dialysis treatment, identifying failures related to post-dialysis assessment, monitoring, communication, and documentation.
- All residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse and/or RN, including direct inspection of the hemodialysis access site, vital signs, bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN.
- The DON and Medical Records staff conducted an audit on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents receiving hemodialysis treatment, finding no other residents with deficiencies similar to those found for Resident 1.
- The Administrator and the DON reviewed and updated the P&P on Dialysis Care. The Dialysis Flow Sheet-Return Assessment form was updated to include signature columns for the Charge Nurse and RN Supervisor, as well as the inclusion of the Nursing Facility Pre and Post Dialysis Assessment form. The updated policy became effective and will be presented to the Quality Assurance Committee at the next monthly meeting.
- The Administrator notified the Medical Director regarding the details of the IJ issued by the SSA and the updated policy on Dialysis Care.
- The DON provided one-on-one in-service to RN 1 and LVN 1, who were assigned to Resident 1 during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care, focusing on conducting pre and post dialysis assessments, assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications, and documentation requirements.
- The facility will ensure that residents who require hemodialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
- The DON and DSD provided in-service education to nursing staff regarding the updated policy on Dialysis Care, with emphasis on comprehensive assessment and monitoring of residents by LVNs or RNs post dialysis treatment, completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment, and nursing progress notes documenting the date and time residents return to the facility.
- The DON performed a competency check of RN 1 regarding dialysis care, including monitoring, documentation, and communication.
- The DON performed competency checks of licensed nurses regarding post dialysis observation, reporting, monitoring, interventions, and proper documentation.
- The DSD performed competency checks of CNAs regarding observation and reporting on resident's return post-dialysis and post procedure, monitoring, safety, and communication of observations.
- The DON conducted an audit on residents who returned from hemodialysis, showing all requirements were completed and in place for each of the reviewed residents, and that a process is in place to ensure appropriate assessment, monitoring, documentation, and clinical oversight for residents returning to the facility following outpatient hemodialysis.
Failure to Ensure Nursing Staff Competency in Dialysis Care and Assessment
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the necessary competencies to provide appropriate care for residents requiring dialysis. Specifically, two of five sampled staff, including a registered nurse and a licensed vocational nurse, did not receive orientation or in-service training on dialysis care, assessment, or site evaluation. Review of their annual skills checklists and job descriptions revealed no documentation of dialysis-related competencies, and interviews with staff confirmed that dialysis care and assessment were not included in their orientation or ongoing training. The Director of Staff Development acknowledged that dialysis care, assessment, and training were not part of the orientation process and had not been provided to nursing staff, including CNAs, until recently. Staff interviews further revealed a lack of instruction on how to assess dialysis sites for thrill and bruit, as well as on procedures for managing residents before and after dialysis treatments. Some staff demonstrated confusion regarding the correct methods for assessing dialysis access sites, indicating gaps in knowledge and skills necessary for safe resident care. The Director of Nursing confirmed that while an in-service on dialysis care was provided in the past year, there was no formal class or consistent inclusion of dialysis care and assessment in new staff orientation. The facility's policy required nursing staff to demonstrate competencies based on resident needs, but this policy was not followed regarding dialysis care. The lack of documented training and competency checks for dialysis care and assessment had the potential to impact the safe provision of nursing care for residents undergoing dialysis.
Failure to Update Facility Assessment Following Ownership and Service Changes
Penalty
Summary
The facility failed to accurately update its Facility Assessment Tool following significant operational changes, including a change of ownership and transition to electronic medical records. The assessment continued to reflect the previous facility name after the approved change of ownership and did not document the adoption of electronic health information technology, despite the facility's transition from paper to electronic records. Additionally, while the assessment listed dialysis as a service provided, it did not specify the necessary staff training or competencies required for dialysis care. These omissions were confirmed during interviews with the Administrator and Director of Nursing, who acknowledged that the Facility Assessment should have been updated to reflect these changes and ensure accurate information regarding services and staff competencies. The facility's policy requires annual and as-needed updates to the Facility Assessment to ensure resources and staff competencies align with resident needs, including during emergencies. However, the assessment was not updated to include the new facility name, the implementation of electronic medical records, or the specific training and competencies for dialysis care. This failure resulted in the Facility Assessment containing outdated and incomplete information, which could misinform staff and the public about the facility's capabilities and resources.
Failure to Accurately Reflect Resident Diagnoses in MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected all current medical diagnoses. Specifically, the MDS did not include a diagnosis of dementia, despite this being documented in the resident's History and Physical (H&P) by the primary physician. The MDS Coordinator acknowledged that during the assessment process, staff relied on the existing admission record rather than reviewing the most recent H&P for new or updated diagnoses. This omission was identified during a review of the resident's records and confirmed in interviews with both the MDS Coordinator and the Director of Nursing (DON). The DON stated that it is the responsibility of the MDS Coordinator to ensure that all diagnoses from the primary physician's notes are accurately reflected in the MDS and the resident's care plan. The facility's policy requires that the Resident Assessment Instrument (RAI) process includes comprehensive and up-to-date information about the resident's health status at the time of assessment. The failure to update the MDS with the dementia diagnosis resulted in an inaccurate assessment for the resident.
Failure to Change Gown Between Residents During Care Activities
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to follow infection control policies and procedures when providing care to two residents. After repositioning one resident who was severely cognitively impaired and dependent on staff for activities of daily living, CNA 1 washed her hands and changed gloves but did not change her gown before proceeding to drain the urinary catheter of another resident in the same room. The second resident had a diagnosis of osteomyelitis and acute kidney failure, required substantial assistance, and had physician orders for enhanced barrier precautions and continuous Foley catheter drainage. CNA 1 acknowledged during the observation that she did not change her gown as required to prevent contamination between residents. The Director of Nursing confirmed that CNA 1 did not follow the facility's infection control protocols, which require staff to change gowns between care activities for residents under isolation precautions. The facility's infection prevention and control policy, last reviewed in June 2025, mandates measures to prevent the development and transmission of infection in accordance with federal and state requirements. The failure to change gowns between residents had the potential to cause cross-contamination.
Failure to Document and Provide Ordered Meals
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met for one sampled resident who was admitted with diagnoses including unspecified heart failure, unspecified atrial fibrillation, and essential hypertension. The resident's nutritional screening and assessment indicated limited assistance was needed and that the resident had chewing and swallowing difficulty. The H&P documented the resident had the capacity to understand and make decisions, while the MDS later indicated severely impaired cognitive skills for daily decisions, supervision with eating, and a physician-prescribed weight loss regimen. The care plan identified the resident as at risk for nutritional problems related to inadequate meal intake and directed staff to provide the ordered diet and monitor and record every meal. A review of the November 2025 nutrition intake documentation showed only one meal entry on 11/6/2025, 11/7/2025, and 11/11/2025, each documenting 26% to 50% intake at evening times. During interview and record review, the MRD stated the resident had only one meal documented on those dates. The DON stated CNAs should accurately document meal intake percentages and refusals to ensure the resident was eating adequately, and acknowledged there was no documentation showing breakfast and lunch were provided on those dates or whether the resident ate or refused those meals. The facility's Nutrition Care and Documentation-Nursing policies stated nursing personnel monitor acceptance and proper diet service at each meal and that CNAs document care provided by the end of the assigned shift.
Failure to Obtain Signed and Dated Witness Statements for Resident Altercation
Penalty
Summary
The facility failed to implement its abuse policy for two residents involved in an altercation because it did not obtain dated and signed witness statements. The facility’s policy titled, Abuse Investigations, stated that witness reports would be obtained in writing and that witnesses would be required to sign and date the reports. During record review and interviews, the Director of Nursing stated the policy was not followed and that the facility had instead interviewed staff and documented the interviews. Resident 1 was admitted with diagnoses including metabolic encephalopathy, DM, and repeated falls. The MDS dated 10/5/2025 indicated the resident’s cognitive skills for daily decisions were moderately impaired and that the resident required maximum assistance with toileting, showering, and dressing. The H&P dated 11/4/2025 stated the resident had the capacity to understand and make decisions. The COC dated 11/9/2025 documented an altercation with Resident 2, in which Resident 1 reported being called names and being hit all over the face, although staff did not witness physical contact and no injuries were noted. Resident 2 was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction affecting the left nondominant side, and history of fall. The H&P dated 9/2/2025 stated the resident had the capacity to understand and make decisions, and the MDS indicated moderately impaired cognitive skills for daily decisions and maximum assistance with toileting, showering, and walking. The COC dated 11/9/2025 documented an altercation with Resident 1, with staff hearing a commotion and observing both residents swinging their hands at each other, but noting no physical contact, no injuries, and no pain. During interviews, the ADON stated she did not ask staff to write their statements and did not know witnesses had to sign and date the statements, while RN 1 stated CNA 1 had written a witness statement and given it to her, and CNA 1 stated she had written a witness statement and gave it to RN 1.
Failure to Address Refusal of Feeding Assistance in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for Resident 4 to address refusal of feeding assistance. Resident 4 was admitted with diagnoses including unspecified heart failure, unspecified atrial fibrillation, and essential hypertension. The admission record showed Resident 4 had the capacity to understand and make decisions, and the nutritional screening and assessment indicated limited assistance was needed along with chewing and swallowing difficulty. The order summary report listed a regular diet with puree texture and thin liquid consistency. A weight variance/hydration evaluation dated 9/10/2025 stated Resident 4 was able to feed self with minimal assistance and had been known to refuse feeding assistance. The MDS dated 9/25/2025 indicated Resident 4's cognitive skills for daily decisions were severely impaired and that Resident 4 needed supervision with eating. The nutritional quarterly progress evaluation dated 9/26/2025 also indicated chewing and swallowing problems, and the care plan dated 10/1/2025 addressed self-care deficit and indicated Resident 4 required supervision with eating. During observation on 11/14/2025, Resident 4 was seen eating pureed food on her own. CNA 2 stated she was supposed to assist Resident 4 with eating, but Resident 4 refused and wanted to eat on her own, and that nurses were aware of the refusal. LVN 4 stated Resident 4 needed feeding assistance at all times and was not aware of the refusal, and both the RD and facility leadership stated Resident 4 had refused feeding assistance and that a care plan should have been created to address the refusal. The facility policy stated each resident's comprehensive care plan should describe services to be furnished and any services not provided due to the resident's exercise of rights, including the right to refuse treatment.
Failure to Follow Blood Pressure Hold Parameter for Hydralazine
Penalty
Summary
The facility failed to provide pharmaceutical services for one sampled resident by not following the physician’s order for hydralazine hydrochloride. Resident 4 was admitted with diagnoses including unspecified heart failure, unspecified atrial fibrillation, and essential hypertension. The resident’s H&P dated 1/16/2025 indicated the resident had the capacity to understand and make decisions, while the MDS dated 9/25/2025 indicated the resident’s cognitive skills for daily decisions were severely impaired. The Order Summary Report dated 6/28/2025 directed hydralazine 10 mg by mouth every 12 hours for hypertension, with instructions to hold the medication if systolic blood pressure was less than 110 mmHg or if heart rate was less than 60 bpm. The MAR showed that on 11/8/2025 at 9:00 p.m., LVN 3 administered hydralazine when the resident’s blood pressure was 100/67 mmHg. During interview and record review, the DSD and DON stated the medication should have been held because the blood pressure was below 110 mmHg and that the order was not followed.
Failure to Timely Investigate and Report Alleged Financial Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of financial abuse involving a resident diagnosed with Alzheimer's Disease, major depressive disorder, and anxiety. The resident was noted to have the ability to understand and be understood, but could not make medical decisions. On the date of the incident, a staff member observed a male family member attempting to have the resident sign a 'Borrower Authorization' form to access the resident's bank information. The Social Services Director (SSD) intervened, questioned the family member, and was denied access to the document. The SSD determined that the resident lacked capacity to make such decisions and reported the incident as financial abuse on the same day. Despite recognizing the incident as potential financial abuse, the SSD did not complete the required five-day report, believing that submitting the SOC341 form was sufficient. The Director of Nursing (DON) later confirmed that the five-day report, which should have been submitted within five days of the incident, was not completed until much later. Facility policy required timely reporting and investigation of abuse allegations, but this protocol was not followed, resulting in a deficient practice.
Failure to Conduct Timely IDT Meeting After Resident Fall
Penalty
Summary
The facility failed to ensure that an interdisciplinary team (IDT) meeting was conducted in a timely manner following a resident's fall, as required by the facility's own policy and procedure. The resident, who had diagnoses including atrial fibrillation, congestive heart failure, and type 2 diabetes, experienced a fall after attempting to steady herself on a wheelchair that was out of reach while exiting the bathroom. The resident's care plan identified her as having poor balance, an unsteady gait, and poor safety awareness, with interventions such as keeping the call light within reach and frequent visual checks. After the fall, staff physically assessed the resident and completed documentation, but there was no documented evidence that an IDT meeting occurred within the required 72-hour timeframe to investigate the incident and determine causative factors. Interviews with staff, including an LVN, the Assistant Director of Nursing, and the Director of Nursing, confirmed that facility policy mandates an IDT meeting within 72 hours of a fall to review the event, conduct a root cause analysis, and implement interventions to prevent future incidents. However, the review of the resident's electronic medical record did not show that such a meeting took place after the fall. The facility's Fall Management Program policy specifically requires the IDT-Falls Committee to meet and document their findings and actions within this timeframe, but this protocol was not followed in this case.
Failure to Complete Required Post-Fall Assessment and Documentation
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurately documented, as required by its own policy and procedure. After a resident experienced a fall, the required Post-Fall Assessment & Investigation was not completed or documented in the resident's medical record. The resident, who had diagnoses including atrial fibrillation, congestive heart failure, and diabetes mellitus type 2, reported falling while attempting to steady herself after leaving the bathroom. The fall was witnessed by her roommate, who sought staff assistance. Staff interviews confirmed that, although the facility's policy mandates a Post-Fall Assessment & Investigation following any resident fall, this documentation was not completed for the incident in question. Review of the resident's care plan and medical record showed that the Post-Fall Assessment & Investigation template was created in the electronic record but left incomplete. Both the Assistant Director of Nursing and the Director of Nursing acknowledged that the assessment should have been completed by a registered nurse shortly after the incident, but it was not done. The facility's policy specifically requires this documentation to be maintained in the resident's medical record following a fall, and the failure to do so resulted in an incomplete record for the resident involved.
Failure to Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to show documented evidence that advance directives were discussed and appropriately managed for three sampled residents. For one resident with acute respiratory failure, pneumonia, and cerebral infarction, there was no Advance Directive Acknowledgement Form in the medical chart, despite the resident having intact cognition and the capacity to make decisions. Both the RN and Social Services Designee confirmed the absence of documentation, and the Social Services Designee admitted that although the family was spoken to, there was no proof that information about advance directives was provided. Another resident, admitted with multiple diagnoses including neuropathy and diabetes, had signed an Advance Directive Acknowledgement Form indicating the existence of a living will. However, the actual living will was not present in the resident's chart, and there was no documentation regarding its contents. The responsible Social Services staff member acknowledged forgetting to follow up and obtain a copy of the living will, which was necessary for staff to be aware of and honor the resident's wishes when the resident could no longer make decisions. A third resident, with diagnoses including congestive heart failure and urinary retention, had expressed interest in formulating an advance directive and requested assistance from the Ombudsman. Although the facility faxed a request to the Ombudsman, there was no documented follow-up or evidence in the medical record that assistance was provided or that the process was completed. The Social Services staff and Director both acknowledged that the lack of follow-up and documentation could result in delays or failure to honor the resident's wishes, as the process had been pending for over three months.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four of six sampled residents, as evidenced by multiple deficiencies observed during the survey. For one resident with dementia and other cognitive impairments, the wall clock at the bedside consistently displayed the incorrect time over several days. Staff interviews confirmed awareness of the issue, and facility policy required the clock to be accurate to assist with reality orientation for residents with cognitive deficits. The clock was not corrected in a timely manner, despite its importance for resident orientation. Another resident, who had decision-making capacity and was dependent on staff for several activities of daily living, experienced ongoing issues with broken vertical blinds in their room. The missing and fallen slats were left on the floor, and cardboard was taped to the window to block light, as reported by the resident and observed by staff. The resident expressed dissatisfaction with the situation, stating it had persisted for months. Staff interviews revealed that maintenance requests were not consistently made or followed up on, and the environment was not maintained in a homelike or dignified manner, as required by facility policy. A third resident, identified as high risk for falls and with severe cognitive impairment, was found to have a fall mat at the bedside that was torn and had a side table placed on top of it. Staff acknowledged that the mat should not be torn or have equipment placed on it, as this compromised its function and the homelike appearance of the room. Additionally, another resident with severe cognitive and physical impairments had wall sockets at the head of the bed that were cracked and missing covers. Staff and maintenance personnel confirmed these issues and stated that they should have been addressed immediately to maintain a safe and homelike environment. Facility policies reviewed required prompt maintenance and upkeep of resident rooms, but these were not followed in these instances.
Failure to Ensure Residents' Right to Be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment, as evidenced by multiple instances involving five residents. For one resident with a history of falls and severe cognitive impairment, the facility did not accurately complete the physical restraint assessment form to reflect the use of a bed pad alarm, despite having a physician's order and care plan for fall risk. The restraint assessment did not indicate the current type of restraint or the reason for its use, and the admissions nurse did not document whether less restrictive measures had been attempted prior to the application of the restraint. Another resident with dementia and a history of falls was found to be using a bolstered mattress without a current physician's order, informed consent, restraint assessment, or care plan after discharge from hospice care. The facility continued to use the bolstered mattress as a restraint without completing the necessary documentation or obtaining consent from the resident's representative. Staff interviews confirmed that the required assessments and documentation were only completed after the deficiency was identified. Additional deficiencies were observed for three other residents. Two residents had their beds placed against the wall, which staff acknowledged as a form of restraint that limited the residents' ability to exit the bed from one side. There were no physician's orders, informed consents, restraint assessments, or care plans for this intervention. Another resident had three side rails up and a side table blocking the open side of the bed, also without the required physician's order, informed consent, restraint assessment, or care plan. In all cases, staff interviews confirmed that these interventions were implemented without following the facility's policy and procedure for restraint use, which requires pre-restraining assessment, physician's order, informed consent, and care planning.
Failure to Prevent Unnecessary Psychotropic Medication Use and Chemical Restraint
Penalty
Summary
Two residents were not protected from unnecessary psychotropic medication use, resulting in chemical restraint. One resident was administered Seroquel daily for psychosis, despite lacking a diagnosis of schizophrenia, depression, or bipolar disorder, which are the only acceptable indications for this medication in elderly patients. The resident's records, including the face sheet, care plan, and Minimum Data Set, did not support the use of Seroquel, and a Preadmission Screening and Resident Review confirmed the absence of a serious mental illness. The medication was continued after hospital readmission without proper verification, and the facility's own policies required antipsychotic medications to be used only when necessary for specific, documented conditions. A pharmacy recommendation to discontinue Seroquel due to lack of appropriate diagnosis was not followed up in a timely manner. The recommendation was not signed or dated by the attending physician, and there was no documentation of agreement or alternative action. Additionally, a psychiatrist consultation, as noted in the physician's progress notes, was not initiated after the resident's readmission, and the resident was not included on the list for psychiatric evaluation. Facility staff interviews confirmed that the necessary follow-up actions were not taken, and the resident continued to receive Seroquel unnecessarily. Another resident was prescribed Remeron for depression manifested by poor appetite, but there were no orders for monitoring the specific behavior (poor appetite) or for monitoring potential side effects of the medication. Nursing staff acknowledged missing the required monitoring orders, and the DON confirmed that such monitoring is necessary to determine the effectiveness of the medication and to identify any adverse effects. Facility policies required that psychotropic medications be supported by documented rationale, administered at correct doses and duration, and with adequate monitoring, which was not done in this case.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents in key areas, as observed through record reviews, interviews, and direct observation. For one resident with a history of urinary tract infection, end stage renal disease, and schizophrenia, the facility did not create a care plan addressing the resident's smoking habits, despite the resident being assessed for smoking and requiring supervision and a smoking apron. Staff interviews confirmed that the absence of a smoking care plan could result in staff being unaware of the resident's needs and the necessary safety precautions. Another resident with chronic obstructive pulmonary disease, schizophrenia, and bipolar disorder was prescribed Remeron for depression and poor appetite. However, no care plan was developed to address the use of this medication, including monitoring for side effects and meal intake. Staff acknowledged that the care plan should have been created when the medication was ordered, and the lack of such a plan meant that staff would not know what interventions were in place or how to monitor the resident's response to the medication. Additionally, a resident with acute respiratory failure, COPD, and congestive heart failure was prescribed BiPAP therapy at night, but the care plan did not specify the cleaning schedule or duration of therapy. Observations revealed inconsistent cleaning and documentation practices for the BiPAP equipment, and staff interviews confirmed that the care plan lacked necessary details for proper care and infection control. Furthermore, two residents receiving antianxiety and psychotropic medications did not have care plans addressing the use of these drugs, their potential side effects, or monitoring requirements. Staff interviews indicated that the absence of these care plans could lead to unrecognized adverse effects and inconsistent care.
Failure to Revise Care Plans for Infection Control and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised in a timely manner for three residents, resulting in deficiencies related to infection control and pressure ulcer prevention. For one resident with a history of vancomycin-resistant enterococcus (VRE) in the urine, the care plan was not updated to reflect the discontinuation of contact isolation and the implementation of enhanced barrier precautions (EBP) as ordered by the physician. Both the Infection Preventionist and the Director of Nursing confirmed that the care plan should have been revised to indicate the current precaution status, but it was not, which could create confusion among staff regarding the appropriate infection control measures. Two other residents, both at high risk for developing pressure ulcers, had physician orders for the use of low air loss mattresses (LALM) to preserve skin integrity. However, their care plans were not updated to include the LALM as an intervention for pressure ulcer prevention. Observations revealed that the LALM settings for both residents did not match their current weights, as required by manufacturer specifications and facility policy. Nursing staff acknowledged that the care plans should have been revised to reflect the use of LALM and that the settings should be adjusted according to the residents' weights to prevent skin breakdown. The facility's policy requires that care plans be developed and implemented within seven days of the comprehensive assessment and be reviewed and updated when there are changes in the resident's condition or interventions. Despite this, the care plans for these residents were not revised to reflect current orders and interventions, leading to potential miscommunication among staff and a delay in necessary care and services. The deficiencies were identified through record reviews, staff interviews, and direct observations.
Failure to Rotate Insulin Injection Sites for Two Residents
Penalty
Summary
The facility failed to provide care in accordance with professional standards for two residents who were prescribed subcutaneous insulin, by not rotating the injection sites as required by physician orders, facility policy, and manufacturer guidelines. For one resident with severe cognitive impairment and total dependence on staff for activities of daily living, insulin was repeatedly administered in the same abdominal quadrants over several weeks, despite clear orders and documentation requiring site rotation. Both the registered nurse and the director of nursing confirmed that the administration sites were not rotated, acknowledging that this was not in compliance with professional standards or the physician's orders. Another resident, who was alert and oriented but had a history of diabetes and hemiplegia, also received insulin injections at the same sites on the abdomen and arm over a period of months. Medication administration records showed multiple instances where the injection sites were not rotated, contrary to the facility's policy and the manufacturer's prescribing information. Nursing staff confirmed that the sites were not rotated as required, and the director of nursing acknowledged that this practice did not follow established guidelines. Facility policy on insulin administration, as well as the manufacturer's guidelines for both types of insulin used, specifically require rotation of injection sites to prevent complications. The failure to rotate sites was confirmed through interviews with nursing staff and review of medical records, which documented repeated use of the same injection locations for both residents. This practice was not in accordance with professional standards, physician orders, or the facility's own procedures.
Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for multiple residents. In several instances, medications were left unattended and accessible in residents' shared rooms, despite assessments indicating that these residents were not safe candidates for self-administration. For example, one resident had a cup containing multiple medications left on the bedside table by an LVN, who stated that the resident preferred to take medications one at a time. However, there was no physician's order or assessment supporting self-administration, and facility policy required direct observation during medication administration. Additionally, topical medications such as A&D ointment were left at the bedside and on the floor, and were applied by a CNA without a physician's order, contrary to facility policy and scope of practice requirements. Hazardous materials were also found in resident rooms without proper supervision. One resident had a large aerosol can of bug spray stored on a dresser next to food items. Staff who observed the spray did not remove it, despite facility policy prohibiting hazardous chemicals in resident rooms and the potential for confused or wandering residents to misuse such items. The Director of Nursing confirmed that the presence of bug spray in a resident's room was not in accordance with facility policy and posed a risk to residents. Environmental hazards were present in the form of improper use and maintenance of safety equipment. Several residents who were at risk for falls had floor mats intended to prevent injury, but these mats were obstructed by furniture or medical equipment, such as visitor chairs and overbed tables, which compromised their effectiveness. In one case, a resident's fall mat had a significant tear, and in others, beds were not maintained in the lowest position as required by care plans. Additionally, a resident was found using a heating pad without a physician's order, and another had a bed remote with frayed wires, both of which posed risks of injury or electrocution. These deficiencies were observed during interviews and record reviews, and staff acknowledged that such practices were not in line with facility policies and procedures.
Deficient Respiratory Care and Infection Control for Residents Requiring Oxygen and BiPAP
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care and services in accordance with professional standards of practice for four residents requiring respiratory support. For one resident with acute respiratory failure, COPD, and CHF, the BiPAP mask was observed hanging on the wheelchair brake handle, not stored in a manner free from contamination. The BiPAP mask and nebulizer were stored together in an unlabelled plastic bag, lacking the resident's name and the date of last change. Staff interviews revealed inconsistent cleaning practices for the BiPAP mask, with some staff using alcohol wipes and others using soap and water, but without documentation of cleaning or adherence to the manufacturer's instructions. The care plan did not specify cleaning frequency or duration of BiPAP therapy, and administration records lacked consistent documentation of BiPAP use and cleaning, contrary to facility policy and manufacturer guidelines. For three other residents with diagnoses including acute respiratory failure, pneumonia, and COPD, oxygen was administered via nasal cannula or nebulizer, but the tubing and masks were not labeled with the date of last change. In some cases, nebulizer equipment was observed stored in a plastic bag with an outdated date, and in others, the tubing was not dated at all. Staff interviews confirmed that respiratory tubing and masks should be labeled and changed at regular intervals, as per facility policy, but this was not consistently done. The facility's policies required disposable supplies to be changed every 5 to 10 days and labeled with the date of last change, but these procedures were not followed. The Director of Nursing and other staff acknowledged that failure to clean and document respiratory equipment care, as well as improper storage and labeling, could lead to bacterial accumulation and potential infection. Facility policies and manufacturer instructions were reviewed, all of which emphasized the importance of regular cleaning, proper storage, and documentation of respiratory care. However, observations and staff interviews demonstrated that these standards were not consistently met for the residents reviewed, resulting in deficiencies in respiratory care and infection control practices.
Failure to Ensure Accurate Medication Administration and Proper Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for multiple residents. In several instances, medications were not administered according to physician orders. For example, one resident received a lower dose of docusate sodium than prescribed, and another was nearly given expired medication, which was only prevented by surveyor intervention. Additionally, medications were administered outside the required time frames, with some residents receiving their scheduled morning medications significantly late, and without proper documentation or physician notification regarding the delay. The facility also failed to maintain proper medication disposal practices. The Discarded Medication Log was incomplete, lacking required dates, signatures, and witness documentation for numerous medications belonging to several residents. Unlabeled and expired medications, such as meropenem vials, were found stored in the medication cart after the prescribed course was completed, contrary to facility policy. These lapses were confirmed through interviews with nursing staff and the DON, who acknowledged that the required procedures for medication destruction and documentation were not followed. Furthermore, medication administration practices were not consistently supervised. In one case, a nurse left multiple medications at a resident's bedside for self-administration, despite the resident not being assessed or authorized for self-administration. The medications were taken late, outside the scheduled administration window, and without staff observation, which was contrary to both physician orders and facility policy. These deficiencies were identified through direct observation, record review, and staff interviews, all of which confirmed that established protocols for medication administration and documentation were not adhered to.
Failure to Rotate Insulin Injection Sites for Two Residents
Penalty
Summary
The facility failed to ensure that insulin administration sites were rotated for two residents who were prescribed subcutaneous insulin, as required by physician orders, manufacturer guidelines, and professional standards. For one resident with a history of hemiplegia, diabetes mellitus, and gastrostomy status, records showed that insulin injections were repeatedly administered in the same abdominal quadrants over an extended period. Both the registered nurse and the Director of Nursing confirmed that the administration sites were not rotated as ordered, acknowledging that this practice did not comply with the physician's instructions, manufacturer recommendations, or facility policy. Another resident, diagnosed with type 2 diabetes mellitus and other conditions, also received insulin injections at non-rotated sites, primarily in the same abdominal quadrants. Medication administration records indicated multiple instances where the injection sites were not alternated. Interviews with nursing staff and the DON confirmed that the failure to rotate sites was a medication error, as it was not in accordance with the physician's order, manufacturer specifications, or accepted professional standards. Facility policies and procedures, as well as manufacturer guidelines for both types of insulin used, explicitly required rotation of injection sites to prevent adverse effects and ensure proper absorption. The facility's own definition of a medication error included failure to follow these requirements. The survey findings were based on direct record review, staff interviews, and policy examination, all of which demonstrated that the facility did not adhere to established protocols for insulin administration for the two residents reviewed.
Unlabeled and Expired Medications Found in Medication Storage Areas
Penalty
Summary
Surveyors identified several deficiencies in the facility's management of medications and biologicals. In the medication room of Station A, two vials of meropenem, an intravenous antibiotic, were found unlabeled in the IV cart. The registered nurse confirmed that these vials should have been discarded after the prescribed course was completed, but they remained in the cart without proper labeling. Review of the resident's records indicated that the meropenem treatment had concluded, and the extra vials delivered by the pharmacy were not disposed of as required. In Station B, expired medications were found in the medication cart during inspection with the Infection Preventionist. Specifically, a container of psyllium and a bottle of docusate sodium, both used to treat constipation, were discovered with expiration dates that had already passed. The Infection Preventionist and Director of Staff Development both acknowledged that expired medications should be discarded, and that nurses are responsible for checking and removing such items from the cart. Further interviews with nursing staff confirmed that expired medications should not be present in medication carts and that staff are expected to check expiration dates before administration. The Director of Nursing reviewed facility policies, which require the disposal of expired and unlabeled medications and prohibit their storage or use. The presence of expired and unlabeled medications in both the medication room and carts was acknowledged as a failure to follow these established policies.
Pureed Food Consistency Not Maintained for Dysphagia Diets
Penalty
Summary
The facility failed to prepare pureed foods in a form designed to meet the individual needs of residents on a dysphagia puree diet, as required by the International Dysphagia Diet Initiative (IDDSI) Level 4 standards. During observation of the trayline, pureed mixed vegetables were found to be too thick and did not pass the spoon tilt test, which is used to assess the appropriate consistency for safe swallowing. Staff responsible for preparing the puree did not perform the required spoon tilt test, instead relying solely on mixing and visual assessment. The Dietary Director confirmed that the puree mixed vegetables did not fall off the spoon as required and acknowledged that the consistency should have been adjusted by adding more liquid. Review of facility policies and recipes indicated that all IDDSI texture modifications must pass established testing methods at the start and every 15 minutes during service. The facility's diet manual and IDDSI guidelines specify that pureed foods must not be sticky, must fall off the spoon in a single spoonful, and must not have liquid separation. Despite these requirements, the puree mixed vegetables served did not meet the necessary consistency standards, potentially affecting all residents on a puree diet at the time of the survey.
Deficient Food Storage, Labeling, and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, labeling, and sanitation practices. During a kitchen tour, a dietary aide identified several food items, including tomato soup and stewed prunes, that were not disposed of by their expiration dates. Additionally, various produce items such as mixed grapes, oranges, apples, carrots, purple cabbage, and leafy lettuce were found without proper labeling of received or expiration dates. Other items, such as grated Parmesan cheese and sliced deli meat, were missing required opened and expired dates. A frozen pepperoni bag was also incorrectly labeled with an expiration date. Further observations revealed improper storage practices, such as sliced cheeses being mixed with avocados and grapes in a single bin, which the dietary aide acknowledged should not occur due to contamination risks. A bin of thickener powder was found in the dry storage room without a product name, opened date, or expiration date, and was not stored in its original packaging as required. One of three plate warmer machines was found to have dried food debris, indicating it had not been cleaned as per facility policy. Interviews with the dietary director confirmed that staff are expected to inspect, label, and date all food items upon receipt and opening, and to store produce separately to prevent cross-contamination. The director also stated that opened food items should be discarded after three days and that equipment should be kept clean and in optimal working condition. Facility policies reviewed by surveyors supported these expectations, indicating that the observed practices were not in compliance with established procedures.
Failure to Implement Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for multiple residents, as evidenced by surveyor observations, interviews, and record reviews. For one resident with a history of vancomycin-resistant enterococcus (VRE), staff did not implement Enhanced Barrier Precautions (EBP) as ordered, including the absence of required signage and personal protective equipment (PPE) at the room entrance. Staff members entered the resident's room and provided care, such as medication administration and linen changes, without wearing gowns, contrary to facility policy and physician orders. The Infection Preventionist and Director of Nursing confirmed that EBP should have been implemented for this resident due to their history of multidrug-resistant organisms (MDROs), but it was not done. In another instance, a Restorative Nursing Aide used a cloth gait belt with a resident on EBP and failed to properly disinfect it between uses. The aide stated she used bleach wipes on the cloth gait belt and then used it with another resident. The Infection Preventionist clarified that cloth gait belts are porous and cannot be properly disinfected with wipes, and that only vinyl gait belts should be used. The Director of Nursing confirmed that improper disinfection of shared equipment could lead to the spread of infection. Additionally, multiple medication carts were found with Prostat supplement bottles that were sticky and had visible drippings, indicating they were not cleaned before and after use as required by facility policy. Further deficiencies included staff not wearing gowns during high-contact care activities for residents on EBP, such as providing bed baths, and not securing gowns properly during medication administration. Linen carts were observed with loosely woven mesh covers that did not fully protect linens from dust. In the respiratory care area, a BiPAP mask was not stored in a manner free from contamination, and the nebulizer was not labeled with the resident's name or date last changed. Documentation and cleaning of the BiPAP equipment were inconsistent and not in accordance with physician orders or manufacturer instructions. These practices were confirmed by staff interviews and policy reviews, demonstrating a failure to follow established infection control protocols.
Cluttered Therapy Gym Limits Resident Access to Rehabilitative Services
Penalty
Summary
Facility staff failed to provide sufficient space and appropriate storage for equipment in the Physical Therapy (PT) gym, resulting in the therapy mat and surrounding area being used to store various items, including therapy balls, broken equipment, assistive devices, and items meant for disposal. Observations revealed that these items were stacked on and around the therapy mat, rendering the area unusable for resident therapy sessions. The Director of Rehabilitation confirmed that the therapy mat and its surrounding area could not be used for therapy due to the clutter and that items stored there were awaiting disposal. Interviews with facility leadership, including the Director of Nursing, emphasized the importance of maintaining a tidy, homelike, and hazard-free therapy environment, and acknowledged that the current use of the therapy area for storage was inappropriate. A review of facility policy indicated an expectation for cleanliness and order to promote a homelike environment, but there was no specific policy addressing the maintenance of uncluttered therapy areas or prohibiting the use of therapy spaces for storage.
Failure to Maintain Safe Equipment and Environment for Residents
Penalty
Summary
The facility failed to maintain essential equipment in safe working condition in several areas, as observed during surveyor inspections. In the kitchen, the light bulb inside the freezer used to store milk was found to be non-functional. Staff members, including the Dietary Aide and Dietary Director, were unaware of the issue, and the broken bulb had not been reported or addressed. Facility policy required that equipment be kept in optimal working condition and that staff notify supervisors and maintenance when repairs are needed, but this process was not followed. In the resident care areas, two residents were affected by unsafe equipment conditions. One resident, with a history of dementia, cerebral palsy, and high fall risk, was found with a bed controller that had exposed wires at its base. Multiple staff, including a CNA, Maintenance Supervisor, and DON, confirmed the presence of exposed wires and acknowledged that maintenance should have been notified immediately. The facility's policies emphasized the importance of maintaining equipment in good repair and ensuring a safe environment, but the required notifications and repairs were not made in a timely manner. Another resident, who had hemiplegia, aphasia, and was also at high risk for falls, was found to have wall sockets at the head of the bed that were cracked and missing covers. Staff interviews confirmed that these hazards had not been reported to maintenance as required. Facility policies outlined the responsibility of staff to identify and report hazards and for maintenance to keep the environment safe and homelike, but these procedures were not followed, resulting in unsafe conditions for the residents.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) assisted a resident with breakfast while standing over the resident, rather than sitting at eye level as required by facility policy. The resident involved had a history of pneumonia, dementia, and major depressive disorder, and was assessed as having severely impaired cognition and requiring total assistance with all activities of daily living. During the observation, the resident was in bed with the head elevated, and the CNA admitted to forgetting to get a chair, acknowledging that staff should be at eye level to respect the resident's dignity during mealtime assistance. Interviews with the Registered Nurse (RN) and Director of Nursing (DON) confirmed that staff are expected to sit at eye level when assisting residents with eating, both for dignity and safety reasons. Facility policies reviewed also specified that residents should be assisted with meals in a manner that maintains their dignity, explicitly stating that staff should not stand over residents while feeding them. The failure to follow these procedures resulted in care that did not maintain the resident's dignity.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4,441 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sylmar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain View Conv Hosp | 0.6 mi | ★★★★★ | 39 | 0 |
| The Grove Post-acute Care Center | 0.9 mi | ★★★★★ | 40 | 0 |
| Maclay Healthcare Center | 1.4 mi | ★★★★★ | 59 | 1 |
| Ararat Nursing Facility | 2.3 mi | ★★★★★ | 27 | 1 |
| Providence Holy Cross Med Ctr D/p Snf | 2.4 mi | ★★★★★ | 17 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.