Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bay Vista Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
A resident with hepatic encephalopathy, type 2 DM, and legal blindness, who required assistance with ADLs, and the resident’s RP repeatedly complained to staff about inconsistent showering and poor hygiene, including the resident being found in dirty clothes and linens before outings and appointments. The RP reported difficulty reaching the SSD, was not informed of the grievance process, and ultimately called law enforcement due to perceived lack of response. Observation showed the resident in stained clothing and on stained sheets, and the resident reported staff did not consistently assist with showers and falsely documented refusals. Review of bathing logs showed only one shower over a 13‑day period with no refusals documented, and an IDT note recorded discussion of the concerns but no investigation or communicated outcome. The SSD and DON acknowledged that the allegations were not entered into the grievance log, the grievance process was not initiated per policy, and only a verbal update was given without written communication of findings, resulting in a failure to honor the resident’s right to voice grievances and receive prompt, documented resolution.
A resident with hepatic encephalopathy, type 2 DM, legal blindness, and moderately impaired cognition, who required assistance with ADLs, did not receive scheduled showers as documented on the bathing log, which showed only one shower over a 13‑day period with no refusals recorded. The resident was observed in stained clothing and on stained bed linens, appearing ungroomed, and reported inconsistent shower assistance and being given only a towel to wash up. The resident and the RP repeatedly complained about inadequate showering, including before medical appointments and outings, but these concerns were not entered into the grievance log, investigated, or communicated back in writing as required by facility policy. An IDT note reflected discussion of the complaints and generalized body dermatitis, yet there was no documentation of a completed investigation or timely communication of findings to the resident or RP.
A resident with Alzheimer's disease, contractures, and abnormal posture had orthopedic devices and PROM placed on hold after swelling and superficial abrasions were identified, and related orders were discontinued and not resumed upon return from a GACH. Despite the absence of active physician orders for restorative services during this period, an RNA documented on the DSR that PROM to bilateral upper and lower extremities and application of a right knee extension splint and PRAFO boots were provided on two occasions, although the RNA later admitted these services were not performed. Review of physician orders confirmed no RNA orders were in place on those dates, and new orders for PROM and device application were entered only later. The DON verified that the services had been on hold and stated that the RNA should not have documented restorative services when there were no orders and the services were not provided, contrary to the facility’s documentation policy requiring accurate records and physician orders before participation in the Restorative Nursing Program.
The facility did not ensure RN coverage for eight consecutive hours each day as required, with staffing records and interviews confirming multiple days without an RN present. This was in direct contrast to the facility's own staffing plan and assessment, which called for continuous RN coverage to meet resident care needs.
Three residents with serious mental illness diagnoses and prescribed psychotropic medications did not have their PASARR Level I screenings accurately completed or reviewed. One resident's PASARR was not reassessed after significant behavioral changes and multiple psychotropic medication orders, while two other residents had negative PASARR results despite clear diagnoses of mental illness. Facility staff acknowledged these errors, which could have led to missed specialized care recommendations.
Surveyors found that kitchen staff did not store an open bag of frozen salisbury steak in a sealed bag in the freezer and failed to label and properly store an open box of hot rice cereal. Staff interviews confirmed these practices did not meet facility policy for food storage and labeling.
The QAA and QAPI groups failed to ensure effective oversight and implementation of corrective actions for previously identified deficiencies, resulting in repeat issues in ADL care, advance directives, infection prevention, quality assurance, food storage, medication error rates, and psychotropic medication use.
The facility did not ensure accurate documentation and follow-up regarding advance directives for two residents, resulting in conflicting or incomplete records about whether advance directives were on file. The Social Services Director acknowledged not following up to clarify or obtain the necessary documentation, despite facility policy requiring written information and proper recordkeeping.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was repeatedly administered PRN Lorazepam for anxiety without documented or attempted non-pharmacological interventions beforehand. Staff observed the resident to be frequently oversedated, requiring repeated prompting for meals and daily care. Facility staff and policy confirmed that non-pharmacological approaches should have been used prior to medication, but this was not done, resulting in the use of medication as a chemical restraint.
Two residents with serious mental illness diagnoses did not receive the required PASARR Level II assessments prior to admission. Despite positive Level I screenings and ongoing psychiatric needs, the PASARR process was not completed due to duplicate entries and misinterpretation of determination letters. Facility staff acknowledged the oversight and the need for new screenings.
A resident with moderate cognitive impairment and mental health diagnoses was not provided with timely shaving assistance despite requesting it and having visibly long, unkempt facial hair. Staff acknowledged the oversight and the facility's policies require such care to be provided daily or as needed, but the care was not rendered as required, impacting the resident's dignity.
Two residents who were identified as good candidates for bowel and bladder retraining did not receive these services, despite being able to communicate their needs and having documented incontinence. Staff confirmed that retraining programs were not implemented, and facility policy requiring such interventions was not followed.
A resident who required continuous oxygen therapy had their nasal cannula left on the floor and the oxygen concentrator left on while not in use. Staff confirmed that the cannula should have been stored in a clean bag and replaced if contaminated, and that the concentrator should have been turned off when not needed. These actions did not meet professional standards for safe and sanitary respiratory care.
A resident with multiple medical conditions and moderate depression repeatedly verbalized a desire to die and refused medications and meals, but staff failed to assess, monitor, or document these behaviors, did not conduct a psychiatric evaluation, and did not implement care plan interventions for suicide risk, resulting in a deficiency in behavioral health care.
A resident with multiple chronic conditions did not receive Onglyza, Sitagliptin, and Risperdal within the required time window, resulting in a medication error rate of 9.09%. The medications were administered more than one hour after the scheduled time, contrary to facility policy, as confirmed by both the nurse and DON.
A resident with diabetes and schizophrenia did not receive Onglyza, Sitagliptin, and Risperdal at the prescribed time, as these medications were administered nearly two hours late, outside the facility's policy window. The error was confirmed by both the LVN and DON, who acknowledged that the medications should have been given within one hour of the scheduled time.
A resident with frequent diarrhea and an order to rule out C. diff was not placed on contact precautions, and staff did not use PPE or collect a stool sample as ordered. Facility staff, including CNAs, LVNs, and the Infection Preventionist Nurse, were not properly notified or did not take action according to policy, resulting in a lack of infection control measures and potential exposure to others.
A resident with severe cognitive impairment and a history of self-injurious behavior sustained a head laceration requiring sutures after staff assigned for 1:1 supervision were not informed of the resident's specific risk of head banging. The CNA was unable to prevent the incident due to lack of information, and the facility failed to follow its own safety policies and care plan interventions.
A resident with metabolic encephalopathy was assaulted by another resident with paranoid schizophrenia using a Wet Floor sign, resulting in a laceration requiring sutures and multiple abrasions. Despite staff intervention, the facility failed to prevent the assault, indicating a lapse in resident safety and abuse prevention measures.
A resident with anxiety and other mental health conditions did not receive their prescribed Ativan due to the facility's failure to order a refill in time and follow procedures for obtaining medication from the emergency kit. The resident missed seven doses, and the licensed nurses did not contact the physician for preauthorization or document the process correctly.
A resident with cognitive impairments and psychiatric conditions eloped from the facility due to inadequate supervision and an unsecured kitchen door. The resident was last seen in their room and was later found missing, with the facility's policy on providing a safe environment not being followed.
The facility failed to prevent two resident-to-resident altercations, resulting in physical harm. In one case, a CNA did not intervene when two residents argued over a wheelchair, leading to one resident throwing a coffee cup at the other. In another incident, a resident with paranoid schizophrenia hit another resident in the face, causing injury. The facility's inadequate monitoring and intervention contributed to these events.
A facility failed to ensure proper medication administration and controlled drug count procedures. An LVN administered Insulin Lispro without verifying the resident's identity with the MAR and documented it before administration. Additionally, two LVNs did not perform a shift-to-shift narcotic count or document it, risking drug accountability. The DON confirmed the importance of following procedures for medication administration and narcotic counts.
The facility's kitchen had unsanitary conditions with a dusty fan and radio near food prep areas. Cold storage equipment, including freezers and a refrigerator, had improper temperatures and ice buildup, compromising food safety. A green substance on the ice dispenser spout raised sanitation concerns. These issues were confirmed by staff and violated the facility's policies on safe food storage and equipment operation.
The facility failed to implement proper infection control practices and water management protocols. A CNA was observed improperly using PPE for a resident under Enhanced Barrier Precautions, with PPE not easily accessible. Staff interviews confirmed this was against infection control protocols. Additionally, the facility did not conduct required water quality testing, risking Legionella exposure, as admitted by the Administrator.
The facility failed to maintain safe operating conditions for three freezers and one refrigerator, risking food-borne illnesses. Observations revealed improper temperatures and ice buildup in the freezers, with one refrigerator reaching 60°F. Interviews indicated a lack of awareness and monitoring, despite policy requirements for safe food storage temperatures.
The facility failed to provide appropriate dialysis care for two residents, leading to potential health risks. Blood pressure was incorrectly measured on the arm with an AV shunt for a resident, and fluid intake was not properly monitored for two residents on hemodialysis. Full pitchers of water were left within reach, and there was no signage indicating fluid restrictions, contrary to the facility's policy.
The facility failed to obtain informed consent before administering psychotropic medications to two residents with bipolar disorder and other conditions. Despite policies requiring consent, it was not documented for Ativan and Olanzapine for one resident, and for Ativan and increased lithium carbonate for another. Observations showed one resident was calm, and staff acknowledged the oversight.
A medication error rate of 7.14% was identified in an LTC facility due to incorrect administration of Calcitonin Salmon Nasal Solution to a resident. The LVN failed to follow physician orders, administering the medication in the wrong nostril and omitting a dose. The resident had moderately impaired cognition and a history of chronic pain. The DON highlighted the risks of not adhering to medication orders.
The facility's QAA and QAPI committees failed to oversee the plan of correction for deficiencies identified in a previous survey, leading to repeat issues in quality of care, pharmaceutical services, medication error rate, infection control, and physical environment. Despite ongoing QAPI initiatives for fall and behavior management, the facility lacked a focused approach to address freezer functionality issues, contributing to the repeat deficiencies.
A resident prescribed antipsychotic and anxiolytic medications was not monitored for bipolar and anxiety behaviors every shift, as required by the facility's protocol. Despite care plans indicating the need for monitoring to support dose reduction, the Medication Administration Record lacked orders for such monitoring. The DON and an LVN confirmed the oversight, which contradicted the facility's policy on documenting behavior occurrences for psychoactive medication use.
A resident with severe cognitive impairment and no teeth was recommended dentures by a dentist. However, the facility failed to notify the responsible party of this recommendation, as confirmed by the Social Service Director. This oversight could delay necessary dental treatment.
A resident with PTSD and depression did not receive an individualized care plan addressing trauma triggers. Despite clear communication abilities, the facility lacked documentation and a care plan for PTSD. The SSD and MDSN LVN were unaware of who was responsible for creating the care plan, and the DON emphasized the importance of staff awareness, which was not reflected in the Interdisciplinary Care Conference.
A resident with a history of aggression was placed in the same room as another aggressive resident, leading to a physical altercation. The facility failed to implement a 1:1 sitter as per the care plan and did not conduct frequent checks, resulting in one resident being injured. The facility's abuse prevention policy was not adequately followed.
Failure to Initiate and Communicate Formal Grievance Process for Hygiene Care Concerns
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to assist a resident and the resident’s responsible party (RP) in filing and processing a formal grievance regarding inconsistent showering and hygiene care. The resident, who was admitted with hepatic encephalopathy, type 2 DM, and legal blindness, had a Minimum Data Set (MDS) indicating moderately impaired cognition but an ability to understand and be understood, and a need for partial to moderate assistance with ADLs. The facility’s policy required staff who overhear or receive a grievance or complaint from a resident or representative to encourage and facilitate completion of a Grievance/Complaint Investigation Report, initiate an investigation, and inform the resident and RP of findings and corrective actions, with all written grievances recorded on the grievance log. The RP reported that during visits in a specified month, the resident appeared in dirty clothes, sitting on dirty bed linens, and not groomed, and that on the resident’s birthday the resident was not showered or prepared for an outing despite the RP’s expectations. The RP stated she attempted multiple times to reach the Social Services Director (SSD) about these concerns but found the SSD difficult to reach and unresponsive. On another occasion, the RP called an LVN the evening before a medical appointment, emphasized the importance of the resident being showered and ready, and was assured this would occur; however, when she arrived the next morning, the resident was in dirty clothes and eating breakfast. The RP reported feeling emotionally stressed, frustrated, and distrustful, ultimately calling law enforcement to make a police report, and stated that the facility did not inform her of the grievance process and did not respond to her complaints or the police report until she filed a complaint with the state survey agency. During observation, the resident was seen lying in bed wearing a stained T‑shirt on bedsheets that appeared stained with gray material and appeared ungroomed. The resident reported frustration about not being able to shower regularly, stating staff did not consistently assist him to the shower and sometimes only provided a towel for washing up. He stated that, as a legally blind person, he needed assistance gathering clothes and supplies and being led to the shower, and that staff accused him of refusing showers, which he denied, saying he would like to shower daily. He reported that he had tried to reach out to the SSD about his complaints, that she did not follow up with him daily, and that he asked his RP to make complaints and grievances on his behalf, but he had not heard a response from the facility regarding these concerns. Record review showed the resident’s bathing log listed scheduled showers on Tuesdays and Fridays, but between two specific dates in February, a 13‑day period, the resident received only one shower, with no documentation of shower refusals. An IDT note dated later in February documented that the team discussed the resident’s and RP’s concerns about lack of showering and characterized the resident as providing exaggerated and inconsistent accounts of care, and also noted generalized body dermatitis on a physician assessment, but there was no documentation that the resident’s allegations were investigated or that outcomes were communicated to the resident or RP. The MDS nurse confirmed that the bathing log showed only one shower in that period and no refusals, and that the IDT note reflected discussion of the concerns without documented follow‑up or resolution communicated to the resident or RP. The SSD stated that as of early March there were no grievances filed by the resident or RP on the grievance log from December through February and that she was not aware of any outstanding grievances. The DON acknowledged being aware of the concerns raised by the resident and RP at the IDT meeting and of the RP’s complaint that the resident did not receive a shower on a specific date, which led to the RP calling the police alleging lack of care. The DON stated the facility did not enter the resident’s and RP’s allegations regarding lack of showers into the grievance log to initiate the grievance process. She also stated that the SSD did not provide a copy of the grievance report related to the police report to the state agency because the facility was still working on completing the grievance form, and that the facility only provided a verbal update to the RP and did not provide the update in writing. The DON stated that failing to follow the facility’s grievance process can result in unresolved issues and resident/RP concerns, and that facility policy requires investigation and resolution of all grievances with clear communication of outcomes to residents and their representatives.
Failure to Provide Scheduled Showers and to Process Hygiene-Related Grievances
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services according to a resident’s needs and preferences, specifically related to hygiene and the handling of grievances about that care. The resident was admitted with diagnoses including hepatic encephalopathy, type 2 DM, and legal blindness, and had moderately impaired cognition but was able to understand and be understood. The resident required partial to moderate assistance with ADLs, including bathing. Despite this, the bathing log from 2/10/2026 to 2/23/2026 showed that the resident, who was scheduled for showers on Tuesdays and Fridays, received only one shower on 2/20/2026 over a 13‑day period, with no documentation of any shower refusals. During an observation on 3/10/2026, the resident was found in bed wearing a stained T‑shirt on stained bedsheets, appearing ungroomed, and reported inconsistent assistance with showering and being given only a towel to wash up at times. The resident and the responsible party (RP) repeatedly reported concerns about inadequate showering and hygiene that were not properly addressed or documented as grievances. The RP stated that during visits in February, the resident was found in dirty clothes and dirty bed linens and not groomed, including on the resident’s birthday when the RP arrived to take the resident to a medical appointment and celebration. The RP reported calling an LVN the evening before a scheduled appointment to request that the resident be showered and ready, and was assured this would occur, but found the resident the next morning in dirty clothes and eating breakfast instead of being prepared. The resident corroborated these concerns, stating that staff accused him of refusing showers, which he denied, and that he would like to shower daily. He also reported developing a rash he believed was related to lack of showering and described specific incidents when he was not provided an opportunity to shower before going out. The facility did not follow its grievance policy in response to these complaints. The RP reported difficulty reaching the SSD and a lack of response to concerns about showers and a subsequent police report. The resident stated he had tried to reach out to the SSD but did not receive daily follow‑up and asked his RP to make complaints on his behalf, yet neither he nor the RP received a response from the facility regarding their concerns. The SSD stated that the grievance log, last updated on 3/3/2026, contained no grievances from the resident or RP from 12/2025 to 2/2026 and that she was not aware of any outstanding grievances. An IDT note dated 2/25/2026 documented that the team discussed the resident’s and RP’s concerns about lack of showering and referenced generalized body dermatitis noted on 2/24/2026, but there was no documentation that the allegations were investigated or that outcomes were communicated to the resident or RP. The DON acknowledged awareness of the concerns raised at the IDT meeting and of the RP’s complaint about the missed shower on 3/2/2026 and the police call, but confirmed that these allegations were not entered into the grievance log to initiate the grievance process, and that the facility did not provide a written update to the RP, contrary to the facility’s written grievance policy.
Inaccurate Restorative Nursing Documentation Without Physician Orders
Penalty
Summary
The deficiency involves inaccurate restorative nursing documentation for a resident when no physician orders were in place and the services were not provided. The resident had Alzheimer's disease, contractures of both ankles and hands, and abnormal posture, and was dependent on staff for toileting, dressing, personal hygiene, and eating. An IDT note documented that orthopedic devices, including PRAFO boots and a right knee extension splint, were placed on hold and orders discontinued after superficial abrasions and skin discoloration were identified on both lower extremities. The resident was discharged to a GACH, and upon discharge the physician's orders directed staff to hold the right knee extension splint, PROM to both lower extremities, and PRAFO boots due to swelling and abrasions; when the resident returned, these previous orders were not resumed. Despite the absence of active physician orders for restorative services on the dates in question, the DSR showed that the RNA documented providing PROM to the resident’s bilateral upper and lower extremities and applying the right knee extension splint and PRAFO boots on two separate occasions. Review of the physician’s orders for those dates confirmed there were no orders for RNA services at that time, and new orders for PROM and application of the right knee splint and PRAFO boots were not entered until several days later. In an interview, the RNA admitted she did not perform the PROM or apply the splint or PRAFOs because there were no physician’s orders and acknowledged that her documentation was entered by mistake. The DON confirmed that the orders for PRAFO boots, right knee splint, and PROM had been held and later resumed, and stated that the RNA should not have documented providing restorative services when there were no orders and the services were not provided, emphasizing that documentation must be accurate so staff know what is being done for residents. The facility’s documentation policy required that resident progress in the Restorative Nursing Program be documented accurately and that physician orders be obtained prior to participation in the program.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week, as required. Record reviews and interviews with the Director of Staff Development and the Administrator confirmed that on multiple specific dates, there was no RN coverage. The facility's own staffing plan indicated that an RN should be present from 7am to 7pm and another from 7pm to 7am, but this was not followed on the identified dates. Both the DSD and the Administrator acknowledged the absence of RN coverage and recognized the importance of having an RN available, particularly for emergencies and advanced care activities. The facility assessment outlined the need for sufficient staff with appropriate competencies to meet residents' needs, including the provision of direct care by RNs. Despite this, the documented staffing records showed gaps in RN coverage, which was confirmed during interviews and record reviews. The deficiency was identified through a review of the facility's census and direct care service hours per patient day, which clearly indicated the days without RN presence.
Failure to Accurately Complete and Review PASARR Level I for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to properly coordinate and complete the Preadmission Screening and Resident Review (PASARR) Level I process for three residents with serious mental illness diagnoses. For one resident, the facility did not review the PASARR Level I submitted by another facility upon admission, despite the resident having diagnoses of paranoid schizophrenia, schizoaffective disorder, depression, and anxiety, as well as exhibiting behavioral issues such as banging her head on the wall. The resident was also prescribed multiple psychotropic medications, and her Minimum Data Set (MDS) indicated severely impaired cognitive skills and the need for assistance with daily activities. The Minimum Data Set Nurse (MDSN) acknowledged that a new PASARR Level I should have been submitted due to significant changes in the resident's condition and behaviors, and that the lack of review could have resulted in missed recommendations for specialized care. For two additional residents, both with documented diagnoses of serious mental illness and prescribed psychotropic medications, the PASARR Level I screenings were completed but inaccurately indicated negative results for serious mental illness. The MDSN confirmed that these screenings should have been positive based on the residents' diagnoses and medication regimens. The facility's policy requires accurate completion and review of PASARR Level I to ensure appropriate care planning and access to specialized services for residents with mental illness or intellectual disabilities. Interviews with facility staff, including the MDSN and Director of Nursing (DON), revealed that the interdisciplinary team is responsible for reviewing PASARRs for accuracy and returning them for correction if necessary. However, in these cases, the PASARRs were not properly reviewed or completed, resulting in the potential for residents not receiving the necessary care and services tailored to their mental health needs.
Failure to Ensure Safe and Sanitary Food Storage and Preparation
Penalty
Summary
Surveyors observed that the facility failed to follow safe and sanitary food storage and preparation practices. Specifically, an open plastic bag of frozen salisbury steaks was found stored in an open carton box in the freezer, rather than in a sealed plastic bag. Additionally, an open box of hot rice cereal was left on the kitchen countertop without an open date label and was not stored in a sealed bag or container. The Dietary Manager (DM) was observed placing the frozen steaks into a plastic bag and returning them to the freezer, and discarding the rice cereal box after noting it was not properly stored or labeled. Interviews with kitchen staff, the DM, and the Registered Dietician (RD) confirmed that open frozen foods should be stored in sealed bags to maintain freshness and prevent contamination, and that open dry food items should be labeled with an open date and stored in sealed containers. The facility's policy and procedure on food storage and handling required all food items to be properly labeled, dated, and stored in airtight containers, which was not followed in these instances.
Repeat Deficiencies Due to Ineffective QAPI Oversight
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) and Quality Assurance Performance Improvement (QAPI) group failed to provide effective oversight and implementation of the facility's plan of correction for previously identified deficient practices. This lack of effective oversight resulted in repeat deficiencies in several key areas, including activities of daily living (ADL) care for dependent residents, formulation of advance directives, infection prevention, quality assurance and performance improvement, food storage, medication error rates, and psychotropic medication use. The repeat deficiencies were identified during the 2024 recertification survey, indicating that the issues had not been adequately addressed since the prior survey. During interviews, the Administrator acknowledged that the QAPI committee was currently focused on falls and behavior management, but recognized that the committee could improve its approach to addressing repeat deficiencies. The facility's policy and procedure for QAPI, dated 2022, outlined a comprehensive program intended to monitor and improve the quality of resident care, but the findings indicate that the program was not effectively implemented to resolve the identified issues. No specific residents or patient medical histories were detailed in the report.
Failure to Accurately Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to ensure that residents' medical records accurately reflected the status of advance directives and that discussions and written information regarding advance directives were properly documented. For one resident with moderate cognitive impairment and diagnoses including psychosis and depression, conflicting documentation was found: one note indicated an advance directive was on file, while a later note stated the resident did not have an advance directive and did not wish to formulate one. For another resident, who was cognitively intact and had diagnoses including COPD and paranoid schizophrenia, the records were inconsistent, with some assessments indicating an advance directive was on file and others stating there was none. The Advance Directive Acknowledgement Form also indicated the resident did not have an advance directive. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) confirmed that the SSD did not follow up to obtain or clarify the advance directive status for these residents, and acknowledged the importance of accurate documentation to ensure residents' wishes are honored. The facility's policy required that residents be provided with written information about advance directives upon admission and that copies of any advance directives be obtained and placed in the medical record, but this process was not consistently followed for the two residents in question.
Failure to Provide Non-Pharmacological Interventions Before PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints by not providing non-pharmacological interventions prior to administering as-needed (PRN) psychotropic medication, specifically Lorazepam, for anxiety. The resident, who had a history of unspecified dementia with psychotic disturbance, schizoaffective disorder, generalized anxiety disorder, and COPD, was observed to have severely impaired cognitive skills and required significant assistance with daily activities. Multiple orders for Lorazepam were documented over several months, with the medication being administered for symptoms such as restlessness and inability to relax. Observations revealed that the resident was frequently sleepy or unresponsive during the day, requiring staff to repeatedly wake her for meals and activities of daily living. Staff interviews confirmed that non-pharmacological interventions were not attempted or documented before administering Lorazepam. Licensed nursing staff acknowledged that the medication could cause oversedation, impacting the resident's ability to participate in daily activities, and that the lack of non-pharmacological interventions could constitute a chemical restraint. Further interviews with facility staff, including the DON and pharmacist consultant, confirmed that best practice and facility policy require non-pharmacological interventions to be used before administering PRN psychotropic medications. Review of the facility's policy indicated that preventable causes of behavior should be considered and non-medication interventions implemented in collaboration with the healthcare team. The failure to follow these procedures resulted in the resident being at risk for adverse effects from unnecessary and prolonged use of psychotropic medication.
Failure to Complete Required PASARR Level II Assessments for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that two residents with diagnoses of serious mental illness received the required Level II Preadmission Screening and Resident Review (PASARR) assessments prior to admission. For one resident, records showed diagnoses of diabetes mellitus, paranoid schizophrenia, major depressive disorder, and anxiety. Despite a positive Level I PASARR screening and ongoing psychiatric needs, the resident's PASARR file was closed due to a duplicate entry, and no new Level I screening was submitted as required. Staff interviews confirmed that a new screening should have been completed due to the resident's mental health history. For the second resident, who had diagnoses including major depressive disorder, anxiety, and bipolar disorder, the admission and assessment records indicated a lack of capacity to make decisions and a need for substantial assistance with daily activities. The PASARR process was not properly followed, as the determination letter was misread and a Level II evaluation was not initiated. Multiple staff members, including the MDS nurse, RN supervisor, and DON, acknowledged that both residents required new Level I screenings and that the PASARR process was not completed according to policy and federal requirements.
Failure to Provide Timely Personal Hygiene Care
Penalty
Summary
A resident with diagnoses of psychosis and depression, who had moderate cognitive impairment and required moderate assistance with personal hygiene, was observed with long, unkempt facial hair and requested to be shaved. Staff, including a CNA and LVN, acknowledged that the resident's facial hair was excessively long and that shaving should have been offered when the need was noticed or when the resident requested it. The CNA indicated that the length of the facial hair required the use of an electric razor, and both the CNA and LVN recognized that not providing shaving upon request could affect the resident's dignity. The facility's policy and procedures, as well as job descriptions for CNAs and LVNs, specify that male residents should be shaved daily or as needed, and that LVNs are responsible for supervising CNAs and ensuring appropriate care is provided. Despite these guidelines, the resident was not provided with timely personal hygiene care, specifically shaving, as required by facility policy and as requested by the resident.
Failure to Implement Bowel and Bladder Retraining Programs for Eligible Residents
Penalty
Summary
The facility failed to provide appropriate bowel and bladder retraining or toileting programs for two residents who were identified as good candidates for such interventions. Both residents had documented episodes of incontinence and were assessed as being able to communicate their needs and benefit from retraining programs. Despite this, neither resident was enrolled in a bowel and bladder retraining program, and staff interviews confirmed that these services were not implemented. For one resident, medical records indicated a history of urinary tract infection, acute cystitis, and mental health conditions, with assessments showing the resident required substantial assistance with toileting and was always incontinent. Staff interviews revealed that the resident could express the need to use the bathroom but was not included in any retraining program, despite a screener indicating suitability for such intervention. Nursing staff were unable to provide a reason for the lack of program implementation. The second resident had diagnoses including hemiplegia, diabetes mellitus, and cirrhosis of the liver, and was also able to communicate needs despite cognitive impairment. This resident experienced episodes of incontinence, expressed a dislike for wearing diapers, and was similarly identified as a good candidate for retraining. However, the retraining program was not initiated, and staff acknowledged that the process was missed. Facility policy required that residents who are incontinent receive services to attain or maintain continence unless clinically inappropriate, but this was not followed for these two residents.
Failure to Maintain Safe and Sanitary Respiratory Care Equipment
Penalty
Summary
A deficiency occurred when a resident who was dependent on supplemental oxygen and had severely impaired cognitive skills did not receive respiratory care consistent with professional standards. The resident's nasal cannula was observed on the floor, with the nasal prongs touching the ground, while still connected to an oxygen concentrator that remained turned on even though the resident was not using it. The resident's care plan required continuous oxygen therapy as ordered by the physician, and the facility's policy specified that oxygen should be administered under safe and sanitary conditions. Multiple staff interviews confirmed that the nasal cannula should not have been left on the floor, as it would be considered contaminated and could lead to infection. Staff also stated that the oxygen concentrator should have been turned off when not in use, and the nasal cannula should have been stored in a clean plastic bag. The facility's policy and staff statements aligned in indicating that the observed practices did not meet the required standards for safe and sanitary respiratory care.
Failure to Provide Behavioral Health Care After Resident's Suicidal Ideation
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary behavioral health care and services to a resident who verbalized suicidal ideation. The resident, who had a history of hemiplegia, hemiparesis, diabetes mellitus, a stage III pressure ulcer, muscle spasms, and muscle weakness, was assessed as having moderately impaired cognitive skills and was dependent on staff for several activities of daily living. The resident's PHQ-9 score indicated moderate depression, and the care plan identified a risk for mood problems, including depression and potential self-harm. Despite the resident's repeated verbalizations of wanting to die and refusal of medications and meals, staff did not consistently assess or monitor the resident's behavior following these statements. Documentation showed that the resident's expressions of suicidal ideation were not followed by appropriate monitoring or assessment, and there was no evidence of a psychiatric evaluation being conducted after these incidents. Staff interviews confirmed that the resident's behavior was not documented in progress notes, and key personnel, including the MDS nurse and social services director, were not informed of the resident's statements. Additionally, the care plan interventions for monitoring and reporting risk for self-harm were not implemented as required. The physician was notified of the resident's medication refusals and suicidal ideation, but there was no follow-up to ensure the resident's safety, such as one-on-one observation or immediate psychiatric assessment. Staff interviews revealed a lack of communication and follow-through, with some staff unaware of the resident's statements and others not receiving responses from medical providers. The facility's policy required comprehensive, interdisciplinary care for behavioral health needs, but this was not carried out in the resident's case.
Medication Error Rate Exceeds 5% Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a medication pass, resulting in a 9.09% error rate. Specifically, a resident with diagnoses including diabetes mellitus, paranoid schizophrenia, bipolar disorder, and anxiety disorder did not receive three scheduled medications—Onglyza, Sitagliptin, and Risperdal—within the required time frame. According to the facility's policy, medications scheduled for 9:00 am should be administered within one hour before or after the scheduled time. However, these medications were administered at 10:48 am, exceeding the allowed window. The error was observed during a medication pass, where the nurse administered other medications to the resident at 8:15 am but failed to give Onglyza, Sitagliptin, and Risperdal at that time. Both the nurse and the Director of Nursing confirmed that the medications were given late and acknowledged the deviation from the facility's medication administration policy. The resident's medical records and assessments indicated moderate cognitive impairment and the need for assistance with activities of daily living, as well as ongoing use of antipsychotic and hypoglycemic medications.
Significant Medication Administration Error Due to Delayed Dosing
Penalty
Summary
A deficiency occurred when a resident with diagnoses including diabetes mellitus type 2, paranoid schizophrenia, bipolar disorder, and anxiety disorder did not receive prescribed medications as ordered. The resident was scheduled to receive Onglyza and Sitagliptin for diabetes, and Risperdal for schizophrenia, at 9:00 am. However, these medications were not administered until 10:48 am, outside the facility's policy window of one hour before or after the scheduled time. Observation showed that only lithium and benztropine were given at 8:15 am, and the remaining medications were delayed. Interviews with the LVN and DON confirmed that the medications were not administered within the required timeframe, and both acknowledged the error. The facility's policy states that medications should be given within one hour before or after the scheduled time, which was not followed in this instance. The failure to administer Onglyza, Sitagliptin, and Risperdal as prescribed constituted a significant medication error for the resident.
Failure to Implement Transmission-Based Precautions for Suspected C. diff Infection
Penalty
Summary
The facility failed to implement transmission-based precautions for a resident who had an order to rule out Clostridium difficile (C. diff) due to frequent diarrhea. The resident, who was admitted with multiple diagnoses including diabetes mellitus, paranoid schizophrenia, major depressive disorder, and anxiety, experienced several episodes of diarrhea and incontinence. Despite these symptoms and an order to collect a stool sample to rule out C. diff, no sample was collected, and the resident was not placed on contact precautions as required by facility policy. Interviews with staff revealed that certified nursing assistants and licensed vocational nurses were aware of the resident's diarrhea and the order to test for C. diff, but did not implement any transmission-based precautions or use personal protective equipment (PPE) when providing care. The Infection Preventionist Nurse was not notified of the resident's symptoms or the need for precautions, and the Director of Nursing confirmed that the resident should have been placed on contact precautions and a stool sample should have been collected. Documentation showed that the resident had been incontinent of stool multiple times over several weeks, but appropriate infection control measures were not initiated. A review of the facility's policies indicated that contact precautions should be implemented for residents suspected of having infections such as C. diff, and that laboratory services should be provided in a timely manner according to physician orders. The failure to follow these policies resulted in a lack of appropriate infection control measures for the resident, potentially exposing other residents, staff, and visitors to the spread of infection.
Failure to Prevent Resident Self-Injury Due to Inadequate Supervision and Communication
Penalty
Summary
A deficiency occurred when a resident with a known history of banging her head on the wall was not adequately protected from self-injury. The resident, who had diagnoses including paranoid schizophrenia, severe cognitive impairment, and was non-compliant with wearing a protective helmet, required 1:1 supervision as ordered by her physician and outlined in her care plan. The care plan also included interventions such as wall padding and close monitoring to minimize injury. Despite these measures, the assigned CNA was not informed about the resident's specific behavior of head banging and believed the supervision was primarily for fall and wandering risks. On the day of the incident, the CNA was seated beside the resident when the resident quickly got up, walked toward the wall, and began banging her head. The CNA was unable to intervene in time to prevent the injury, resulting in the resident sustaining a laceration on her forehead that required six sutures. The CNA later stated that if she had been aware of the resident's head-banging behavior, she would have been more vigilant and positioned herself closer to the resident to prevent such incidents. Interviews with facility staff and review of records confirmed that the CNA was not properly briefed on the resident's risk behaviors, and the facility's policy on resident safety, which requires identification and mitigation of hazards, was not followed. The lack of communication and failure to implement the care plan interventions directly led to the resident's injury.
Resident Assault and Injury Due to Inadequate Protection
Penalty
Summary
The facility failed to protect a resident from physical assault by another resident, resulting in significant injuries. Resident 1, who had a history of metabolic encephalopathy and gait abnormalities, was assaulted by Resident 2 with a Wet Floor sign. This incident led to Resident 1 sustaining a laceration on his right hand that required eight sutures, as well as abrasions on his right forearm, right knee, and left knee. The assault occurred while Resident 1 was in his room, and Resident 2 entered, accusing Resident 1 of killing her family, and proceeded to hit him with the sign. Resident 2, diagnosed with paranoid schizophrenia, exhibited behavioral symptoms of agitation and psychosis on the day of the incident. Despite being able to make consistent and reasonable decisions, Resident 2's aggressive behavior was not adequately managed, leading to the assault. Multiple staff members, including CNAs and a housekeeper, witnessed the incident and attempted to intervene, but not before Resident 1 was injured. The facility's failure to prevent this assault indicates a lapse in ensuring resident safety and protection from abuse. Interviews with staff and observations confirmed the sequence of events and the injuries sustained by Resident 1. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the occurrence of this incident. The administrator acknowledged the responsibility of ensuring resident safety, yet the measures in place were insufficient to prevent the assault. The report highlights the need for improved monitoring and management of residents with behavioral health issues to prevent similar incidents in the future.
Failure to Administer Prescribed Antianxiety Medication
Penalty
Summary
The facility failed to ensure that a resident with anxiety and other mental health conditions received their prescribed antianxiety medication, Ativan, as ordered by their physician. The licensed nurses did not order a refill of Ativan before the medication was depleted, resulting in the resident missing seven doses. The nurses also failed to contact the resident's physician to obtain authorization to access the facility's emergency kit containing Ativan or to follow the facility's policy and procedure for medication ordering and receiving from the pharmacy. The resident, who had a history of anxiety disorder, schizoaffective disorder, major depressive disorder, and bipolar disorder, was admitted to the facility with severe cognitive impairment. The physician's orders indicated that the resident was to receive Ativan 1 mg every 12 hours for anxiety. However, the Medication Administration Record showed that several doses were not administered due to the medication being unavailable and pending pharmacy delivery or physician preauthorization. Interviews with various licensed nurses and supervisors revealed that the nurses did not follow up with the pharmacy or notify the resident's physician for the necessary preauthorization. The facility's policies and procedures were not adhered to, as the nurses did not document the process in the resident's medical record or utilize the emergency kit. The Director of Staff Development and the Administrator confirmed that the medication should have been administered as prescribed and that the necessary steps were not taken to ensure the resident received their medication on time.
Resident Elopement Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring of a resident who lacked the capacity to make decisions, resulting in the resident eloping from the facility. The resident, who had a history of aggressive behavior, bipolar disorder, paranoid schizophrenia, and suicidal ideation, was last seen in his room at approximately 10:30 p.m. on 12/12/2024. The resident was noted missing at approximately 11:30 p.m. on the same day, and as of 12/20/2024, the resident had not been located. The resident's medical records indicated moderate cognitive impairment and a need for supervision or assistance with activities of daily living. Interviews and observations revealed that the facility's kitchen door, which provided access to the main street, was not secured with an alarm system and was only locked when kitchen staff were not present. This unsecured door may have facilitated the resident's elopement. The facility's policy and procedure on resident safety, dated 4/15/2021, stated that the facility would provide a safe and hazard-free environment, which was not adhered to in this instance. The administrator acknowledged that the resident's unknown whereabouts placed them at risk for physical harm due to lack of supervision and medication management for psychiatric behaviors.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two separate incidents involving resident-to-resident altercations. In the first incident, a Certified Nursing Assistant (CNA) did not intervene promptly when two residents were arguing over a wheelchair. This resulted in one resident throwing a coffee cup at another resident, causing a skin abrasion on the head. The CNA admitted to feeling scared and did not separate the residents, despite being aware of their aggressive behaviors and history of altercations. In the second incident, a resident with paranoid schizophrenia and major depressive disorder physically assaulted another resident, hitting them in the face. The assaulted resident, who had paranoid schizophrenia and generalized anxiety disorder, fell to the floor and sustained a facial injury. Staff members were not present to prevent the altercation, and the incident was only addressed after it occurred. The facility's failure to monitor and manage residents with known behavioral issues contributed to this incident. Both incidents highlight the facility's inability to maintain a safe environment for residents with aggressive behaviors. The facility's policies on abuse prevention and resident-to-resident altercations were not effectively implemented, leading to these deficiencies. The lack of adequate staffing and timely intervention by staff members further exacerbated the situation, resulting in harm to the residents involved.
Medication Administration and Controlled Drug Count Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and verification of medication administration for a resident. A Licensed Vocational Nurse (LVN) administered Insulin Lispro to a resident without verifying the resident's identity with the Medication Administration Record (MAR) and documented the medication as administered before actually giving it. This practice increased the risk of medication errors, as the nurse did not have the MAR with her to confirm the correct medication was given to the correct resident. Additionally, the facility did not adhere to its policy regarding the change of shift inventory of controlled medications. Two LVNs failed to perform a shift-to-shift count of narcotics and did not document the count on the facility's controlled drug count record at the beginning and end of their shifts. This lapse in procedure could lead to a loss of accountability and potential drug diversion or theft. The Director of Nursing (DON) confirmed the necessity of following proper procedures for medication administration and narcotic counts. The facility's policies and procedures require that medications be verified with the MAR, administered correctly, and documented immediately after administration. The policies also mandate that a physical inventory of controlled medications be conducted by two licensed nurses at each shift change, with documentation on the controlled medication accountability record.
Sanitation and Equipment Failures in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in its kitchen, as observed during a survey. A dusty fan was positioned near the dishwasher, blowing air onto newly sanitized dishes, and a dusty radio was located close to the kitchen prep table. These unsanitary conditions were confirmed by a dietary aide, who acknowledged that these items should have been removed from the kitchen. The facility's cold storage equipment was not in safe operating condition. Several freezers and a refrigerator were observed with improper temperatures, ice buildup, and lack of temperature monitoring. Freezer #1 lacked a thermometer, and Freezer #2 and #3 had ice buildup and improper temperatures. Freezer #4, which stored various food items, was observed with fluctuating temperatures and ice buildup. The refrigerator storing milk and eggs was found at an unsafe temperature of 60°F. The dietary supervisor confirmed that the equipment should operate at specific temperatures to ensure food safety. Additionally, a green substance was observed on the spout of the ice dispenser, raising concerns about sanitation. The maintenance supervisor confirmed the presence of the substance and acknowledged the need for proper sanitation. The facility's policy and procedure documents indicated that food items must be stored at safe temperatures and that equipment should be operated safely, but these standards were not met during the survey.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented, particularly in the use of personal protective equipment (PPE) for residents under Enhanced Barrier Precautions (EBP). During an initial tour, a Certified Nursing Assistant (CNA) was observed walking in the hallway with gloves on and entering a resident's room with EBP signage. The resident, who had pressure ulcers and was admitted with bipolar disorder, required specific care involving PPE. However, the CNA reported that PPE was not easily accessible, necessitating walking to a distant PPE cart to obtain gloves and gowns. Interviews with staff, including a Licensed Vocational Nurse (LVN) and the Infection Preventionist (IP), confirmed that walking around with gloves or PPE was against infection control protocols. The facility's policy indicated that PPE should be available immediately outside resident rooms to ensure compliance with EBP. Additionally, the facility failed to implement its Water Management Plan effectively, as there was no documentation of water quality testing to prevent the growth and spread of Legionella. The Administrator admitted that the facility's water quality had not been tested, which was a requirement according to the facility's policy and the CDC guidelines. The policy required quarterly measurements of water quality to prevent conditions that could lead to Legionella growth, but this was not adhered to, posing a potential risk of exposure to Legionella and other waterborne infections.
Unsafe Food Storage Conditions in Facility
Penalty
Summary
The facility failed to maintain three freezers and one refrigerator in safe operating condition, which could potentially place residents at risk for food-borne illnesses. During an observation in the facility's food pantry, Freezer #1 was found without a thermometer, and an opened bag of tortillas had no date tag. Freezer #2 had a temperature of 2°F with ice buildup, and Freezer #3 had a temperature of 0°F with ice buildup and a clear liquid on the floor. In the kitchen, Freezer #4 had a temperature of 1°F, and Refrigerator #1 had a temperature of 60°F, which is above the safe operating range. Further observations revealed that Freezer #2's temperature increased to 4°F, and Freezer #3 maintained a temperature of 4°F with continued ice buildup. Refrigerator #1's temperature was later recorded at 38°F with no food items inside, and Freezer #4 was noted to be in a defrost cycle, which was confirmed as normal by the Maintenance Director. However, subsequent checks showed Freezer #4's temperature fluctuating between 18.5°F and 5°F, with ice buildup persisting. Interviews with the Dietary Supervisor and Maintenance Supervisor highlighted that the equipment must operate at proper temperatures to prevent bacterial growth and ensure food safety. The Administrator was unaware of the issues, and the Registered Dietician noted that temperature fluctuations could occur with frequent use but emphasized the need for consistent monitoring. The facility's policy and procedure documents indicated that freezers should maintain temperatures at 0°F or below, and refrigerators should be below 41°F, which was not adhered to in this case.
Inadequate Dialysis Care and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide appropriate dialysis care for two residents, leading to potential health risks. For Resident 47, the facility did not ensure that blood pressure was measured on the correct arm, avoiding the left arm where an arteriovenous (AV) shunt was located. This oversight was observed multiple times, despite the physician's order to avoid taking blood pressure on the arm with the AV shunt. The lack of signage at the bedside to indicate this restriction contributed to the repeated error. The Director of Nursing acknowledged that taking blood pressure on the arm with the AV shunt could cause it to malfunction. Additionally, the facility did not accurately monitor the fluid intake and output for Residents 47 and 26, both of whom were on hemodialysis and had fluid restrictions. Observations revealed that full pitchers of water were left within reach of both residents, with no signage indicating their fluid restrictions. Resident 26 was unaware of her fluid intake limits, and Resident 47's care plan specifically indicated a fluid restriction of 1200 milliliters per day. The facility's policy on dialysis care, which includes monitoring fluid intake and avoiding blood pressure measurements on the arm with the shunt, was not followed.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to two residents, Resident 64 and Resident 41. Resident 64 was admitted with diagnoses including bipolar disorder and unspecified dementia. Despite having clear speech and sometimes understanding others, informed consent was not obtained before starting Ativan on June 25, 2024, and increasing the dosage of lithium carbonate on June 22, 2024. Licensed Vocational Nurse 4 acknowledged the absence of consent and noted that there was no change in Resident 64's condition before initiating the medication. Resident 41, admitted with bipolar disorder and pressure ulcers, also did not have informed consent documented for the administration of Ativan and Olanzapine. The Minimum Data Set indicated that Resident 41 could understand and be understood by others, and exhibited behavioral symptoms one to three days a week. However, during observations, Resident 41 appeared calm and cooperative. The Minimum Data Set Nurse confirmed that consent was not obtained for Ativan and that the consent for Olanzapine was incomplete. The Director of Nursing admitted to not obtaining consent before starting Ativan for Resident 41 and increasing lithium carbonate for Resident 64. The facility's policy requires written informed consent for psychotropic drugs and consent renewal every six months. The policy also mandates that healthcare practitioners obtain informed consent before administering or increasing doses of psychoactive medications, which was not adhered to in these cases.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.14% due to two errors out of 27 opportunities. These errors involved the administration of Calcitonin Salmon Nasal Solution to a resident, who was supposed to receive the medication in alternating nostrils on odd and even days as per the physician's orders. However, the medication was administered incorrectly, with one spray given in the right nostril instead of the left, and an omission of the spray in the left nostril. The resident involved had a history of lumbar intervertebral disc degeneration and chronic pain syndrome and was noted to have moderately impaired cognition. The Licensed Vocational Nurse (LVN) responsible for the administration admitted to confusion regarding the days and failed to verify the correct nostril for administration by checking the Medication Administration Record (MAR) or the pharmacy label. This oversight was acknowledged by the Director of Nursing, who emphasized the importance of following physician orders to prevent adverse reactions and ensure accurate medication records.
Repeat Deficiencies in Quality of Care and Pharmaceutical Services
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to maintain oversight of the plan of correction for deficiencies identified during the previous recertification survey conducted on July 19, 2021. This oversight failure resulted in repeat deficiencies in several areas, including quality of care, pharmaceutical services, medication error rate exceeding five percent, infection control, and physical environment. The facility's Statement of Deficiencies from the 2021 survey highlighted these recurring issues. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility had ongoing QAPI initiatives for fall and behavior management, but lacked a focused QAPI for addressing issues with the facility's freezers, which were identified again during the recertification survey. The facility's policy and procedure for the QAPI program, revised in March 2024, indicated an ongoing effort to monitor and improve the quality of resident care, but the lack of a system to ensure freezer functionality contributed to the repeat deficiencies.
Failure to Monitor Resident's Behavior for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident, who was prescribed antipsychotic and anxiolytic medications, was monitored for behaviors associated with bipolar disorder and anxiety every shift. The resident, identified as having bipolar disorder, anxiety disorder, and major depressive disorder, was prescribed Latuda for bipolar depression and Ativan for anxiety. However, the Medication Administration Record did not include orders for behavioral monitoring of the resident's episodes of bipolar depression and anxiety every shift, as required by the facility's protocol. The care plans for the resident's psychotropic and anti-anxiety medications included goals for dose reduction and monitoring of target behavior symptoms, but these interventions were not implemented. Licensed Vocational Nurse 4 confirmed that the resident had not been monitored every shift for behavioral episodes related to the prescribed medications. The Director of Nursing emphasized the importance of behavior monitoring every shift to justify the use of psychotropic medications. The facility's policy indicated that occurrences of behavior for which psychoactive medications are used should be documented every shift, but this was not done for the resident.
Failure to Notify Responsible Party of Dental Recommendation
Penalty
Summary
The facility failed to notify the responsible party of a resident when the dentist recommended dentures. The resident, who was admitted with diagnoses including metabolic encephalopathy, Alzheimer's disease, and unspecified dementia, lacked the capacity to make medical decisions. The resident's dental notes indicated they were edentulous and unsure about dentures. However, there was no documentation that the responsible party was informed of the dentist's recommendation for dentures after the dental visit. The Social Service Director acknowledged the lack of notification and stated it was their responsibility to inform the responsible party of the dentist's recommendations promptly. Observations confirmed the resident had no upper or lower teeth, and no dentures were found among their belongings. The facility's policy emphasized assisting residents in achieving independent functioning and maintaining dignity, which includes evaluating and addressing individual needs such as adaptive devices. The failure to notify the responsible party could delay necessary dental treatment for the resident.
Failure to Provide Individualized Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to provide an individualized plan of care for a resident with a history of post-traumatic stress disorder (PTSD) and depression. The resident was admitted with diagnoses including PTSD, bipolar disorder, and anxiety disorder. Despite the resident's clear communication abilities, the facility did not have a care plan addressing the resident's PTSD or identifying potential trauma triggers. The Social Services Designee (SSD) acknowledged conducting a trauma-informed care assessment but was unaware of who was responsible for creating the care plan or identifying trauma triggers. The Minimum Data Set Nurse (MDSN LVN) confirmed the absence of a care plan for PTSD and the lack of documentation regarding trauma triggers in the resident's Medication Administration Record (MAR) and nurses' progress notes. The Director of Nursing (DON) stated that it was the responsibility of every licensed nurse to complete the care plan and emphasized the importance of staff being aware of the resident's trauma and triggers to prevent re-traumatization. However, the Interdisciplinary Care Conference did not address these issues, and the facility's policy on trauma-informed care was not followed, leading to the deficiency.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, leading to a serious incident. Resident 1, who had a history of aggressive behavior, was readmitted to the facility and placed in the same room as Resident 2, who also had a history of violent behavior and was previously on a 5150 hold for aggression. Despite Resident 2's care plan requiring a 1:1 sitter to prevent altercations, this was not implemented, and the facility did not assess the compatibility of the two residents sharing a room. On the day of the incident, Resident 1 was attacked by Resident 2, resulting in Resident 1 being punched in the face multiple times, causing a fall and subsequent injuries, including a laceration on the left eyelid and skin tears on the right forearm. The facility's staff failed to conduct frequent checks on the residents, as recommended for those with a history of aggressive behavior, and the room door was closed, which hindered immediate intervention. Interviews with staff revealed that Resident 2 was known to be short-tempered and aggressive, and the facility's Director of Nursing acknowledged that the staff should have monitored Resident 2 more closely and assessed the suitability of rooming the two residents together. The facility's policy on abuse prevention was not adequately followed, leading to the incident and subsequent injury to Resident 1.
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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.
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Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rose Villa Health Care Center | 0.7 mi | ★★★★★ | 6 | 0 |
| Sunset Villa Post Acute | 1 mi | ★★★★★ | 26 | 0 |
| Bellflower Post Acute | 1.4 mi | ★★★★★ | 20 | 0 |
| Cerritos Vista Healthcare Center | 1.8 mi | ★★★★★ | 44 | 0 |
| La Paz Geropsychiatric Center | 2.1 mi | ★★★★★ | 33 | 0 |
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