Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedar Pine Post Acute during CMS and state inspections, most recent first.
Failure to develop individualized care plans for several residents: one resident with a stage 4 sacral pressure ulcer was using a LALM without a care plan, one resident receiving montelukast lacked a care plan for BBW monitoring, one resident with identified activity interests had no activity care plan, and one resident on fluid restriction had no care plan for keeping excess fluids at bedside. Staff and the DON acknowledged the missing care plans and described the related monitoring or interventions that should have been reflected in the care plans.
Failure to provide ADL assistance and nail care: A resident with dementia and COPD was observed eating lunch in bed without staff assistance and without proper HOB elevation, despite needing partial assistance with meals. Two other residents were observed with long, untrimmed fingernails; one had long nails on both hands, and another had long, jagged, dirty nails with debris under them. Staff and the DON acknowledged the grooming and personal hygiene needs, and the care plans were incomplete for these ADL needs.
The facility failed to ensure LALMs were set according to resident weight for two residents. One resident with DM, osteoarthritis, and severe cognitive impairment had a mattress set at about 225 lbs despite weighing 158 lbs, and staff confirmed the setting was incorrect. Another resident with cirrhosis, a history of a stage II pressure ulcer, and severe cognitive impairment had a mattress set at 260 lbs despite weighing 152 lbs; the resident said the bed was hard and hurt his back a little bit. The DON stated the orders, care plan, and facility policy required weight-based settings, but the mattresses were not set that way.
Failure to provide ordered catheter care and UTI prevention measures for two residents with indwelling catheters. One resident's catheter tubing was observed with sediment, and staff acknowledged the care was not completed every shift as ordered. For the other resident, the TAR showed multiple missed or undocumented catheter care entries over several days, despite the care plan and MD order requiring every-shift catheter care with soap and water around the urinary meatus.
A facility failed to complete required dialysis-related care for three residents receiving hemodialysis. For one resident, the AV shunt was not assessed and documented before and after dialysis on multiple occasions. For two other residents, ordered I&O monitoring was not consistently recorded each shift, and one resident’s CBC and BMP were completed monthly instead of weekly as ordered by the MD.
Failure to Maintain Resident Dignity and Timely Meal Service: Two residents were affected by dignity-related failures. One resident with hemiplegia, dysphagia, and severe cognitive impairment was observed drooling on the shirt in the dining room and later in the hallway while visitors and other residents passed by, and staff acknowledged the resident should have been kept clean and the mouth wiped frequently. Another resident with diabetes, HTN, hallux valgus, and dysphagia reported repeated late meal trays; staff confirmed breakfast and lunch trays were served outside the posted mealtimes, and the DON acknowledged late trays could become cold and feel disrespectful.
A resident with muscle weakness, HIV, and dementia was found in bed without his call light within reach; it was tucked behind his back. The resident said he could not find it, and a CNA stated he would be unable to call for help if in distress. The DON confirmed the facility policy requires the call light to be immediately within reach when a resident is in bed.
Unclean and Cluttered Resident Room During Meal: A resident with dementia, schizoaffective disorder, and anxiety disorder was observed sitting in a wheelchair during a meal with a lunch tray on a bedside table while a pillow and clothes were on the floor near a trash can, a used/soiled diaper was on the floor in front of the wheelchair, and a hairbrush was on the tray. The resident’s care plan called for a safe, uncluttered environment, and staff stated the room should have been clean, sanitary, clutter free, and homelike.
Delayed Podiatry Consult for a Resident with Thick Toenails A resident with lymphedema, bilateral LE cellulitis, and significant ADL dependence requested podiatry care for long, thick, yellow toenails that he could not reach. Although a podiatrist visited the facility, the resident was not seen because he was not on the scheduled list, and an RNS did not pass the request on, document it, or notify SSD. The DON stated the miscommunication delayed podiatry services and affected the resident's emotions and self-esteem.
A resident with cirrhosis, anxiety disorder, and severe cognitive impairment was ordered continuous O2 at 2 LPM via NC, titratable up to 5 LPM, with SpO2 checks every shift. Staff observed the resident sleeping with the oxygen concentrator set above 5 LPM, and an LVN, RN supervisor, and DON confirmed the setting was incorrect. The TAR lacked repeated documentation of SpO2 and oxygen level, and the care plan did not include goals or interventions for respiratory assessments, SpO2 monitoring, or checking the oxygen setting.
An LVN did not administer one resident’s Keppra, Lexapro, and metformin at the ordered time, and another resident’s metoprolol ER was given without breakfast as ordered. The residents had diagnoses including epilepsy, DM, depression, HTN, and ASHD, and staff interviews confirmed the medications were not administered according to the physician orders or the facility’s medication administration policy.
A pharmacist review failed to identify and follow up on medication irregularities for two residents. One resident receiving montelukast had a BBW monitoring need noted in the MRR, but no care plan was in place for the required monitoring. Another resident with dementia had a donepezil order written for cognitive impairment instead of dementia, and the consultant pharmacist made no recommendation to clarify the indication despite staff confirming the diagnosis was incorrect.
A resident with dementia, schizoaffective disorder, and anxiety disorder had a donepezil HCL order listed for “cognitive impairment” instead of dementia. RN and RNS both verified the order and stated the diagnosis used as the indication was incorrect, and the facility policy required a diagnosis to justify medication use.
Medication administration errors exceeded the allowed rate when surveyors observed 4 errors in 27 opportunities. An LPN gave one resident's Keppra, Lexapro, and metformin late despite orders for 9 AM administration, and another LPN gave a resident's metoprolol without breakfast even though the order required it with breakfast. The DON confirmed the facility policy required medications to be given within one hour of the ordered time, and staff acknowledged the orders were not followed.
An LVN failed to give one resident’s Keppra, metformin, and Lexapro on time, despite the MAR showing all three were due at 9 AM and the nurse acknowledging they were already more than an hour late. Another LVN failed to give a second resident’s metoprolol with breakfast as ordered. The DON reviewed the facility P&P, which required meds to be given within one hour before or after the ordered time.
Incomplete documentation for LALM use: A resident admitted with a stage 4 sacral pressure ulcer was observed on a low air loss mattress, but the chart had no MD order and no progress note or TAR documentation showing the mattress was in use. The MDS also did not indicate a pressure-reducing device for the bed, while the DON confirmed the facility policy required an MD order and complete documentation for the treatment.
A CNA assisted a resident with eating after touching her eyeglasses without performing hand hygiene, then handled the resident’s food tray and drinking cups. In a separate event, a resident receiving Jevity via G-tube had a feeding pump observed with dried tan stains on the top and sides. The RN supervisor and DON stated the pump should be kept clean, and facility policies addressed hand hygiene, food handling, and keeping enteral feeding equipment clean.
A resident with pain, anxiety, depression, and moderate cognitive impairment had an order for PRN oxycodone HCL. During a narcotic count, staff found a discrepancy between the MAR and the controlled-drug count, with one tablet missing from the expected count. The resident said he received the medication from an LPN around 6:00 a.m., and the LPN later stated he gave the dose but forgot to document it in the MAR and narcotic sheet, contrary to facility policy requiring immediate charting and documented controlled-drug counts.
The facility failed to reconcile and implement a GACH discharge order for long-acting insulin (insulin glargine) for a resident with diabetes, ESRD, and COPD. The hospital discharge list included daily glargine, but on admission the facility only obtained and administered short-acting insulin lispro before meals, with no long-acting insulin ordered for over a month. The resident reported that he had long used both long- and short-acting insulin at home and that in the facility he initially received only short-acting insulin. Review of the MARs with an RN confirmed the absence of a glargine order until mid-April despite persistently high blood sugars, and the DON acknowledged that the admitting nurse did not fully follow the hospital discharge medication list. This failure resulted in hyperglycemia and transfer to the hospital, with documented risk for DKA, dehydration, confusion, and coma.
A resident with cancer, malnutrition, and recent hypotension had a physician’s order for peripheral IV NS hydration over four hours on three consecutive days. The IV hydration ordered for the first day was not administered as scheduled and was instead initiated late the following day by an RN, who reported that the prior shift had not carried out the order and that no IV line was in place at the start of her shift. The DON later stated she was unaware of the missed dose and acknowledged the importance of the hydration given the resident’s hypotension. Facility IV P&P required timely initiation of infusion therapy when ordered and available from the e-kit, but this was not followed.
Surveyors found that staff failed to complete and accurately document neurological evaluation flow sheets and fall risk assessments for two residents. One resident with a history of falls had an incomplete fall risk assessment, omitting key items such as ambulation/elimination status, gait/balance, and systolic BP, which led to an inaccurately low fall risk score. The same resident’s neuro checks were not performed or recorded at all required times, and respiratory patterns were charted with incorrect numerical entries instead of the specified letter codes. For another cognitively impaired resident with prior falls, respiratory patterns on the neuro flow sheet were documented using a non-approved letter that was not listed in the form’s instructions. These practices did not meet the facility’s policy requiring objective, complete, and accurate documentation using only approved abbreviations and symbols, and were cited as having the potential to cause miscommunication and improper care.
A resident with multiple chronic conditions was admitted with personal belongings that were not fully checked, as the resident did not allow a CNA to inspect a purse. During night care, a CNA found a semi-clear hard substance on the resident’s lower back but assumed it was candy. After the resident died, an LVN found a container with a similar substance in the resident’s belongings while searching for family contact information and showed it to staff. The LVN initially told the ADM and DON, and it was reported to the state, that a police officer had discovered the container, but later admitted he had found it himself. The CNA’s observation of a similar substance on the resident’s skin was not reported to administration, and the CNA was not interviewed during the internal investigation. As a result, the written report to the state did not accurately reflect who discovered the suspected contraband or all staff observations, contrary to facility policies on contraband and unusual occurrence reporting.
Two residents did not receive their scheduled morning medications within the required time frame, and one resident's medications were left unattended at the bedside. Nursing staff acknowledged that medications were overdue and that facility policy, which prohibits leaving medications unattended and requires administration within a specific window, was not followed. The DON confirmed that no residents were authorized for self-administration and that staff should observe medication intake.
Two residents engaged in non-consensual sexual activity in a hallway, witnessed by staff, due to inadequate supervision and insufficient care planning for one resident's disruptive behaviors. The facility lacked a policy on consensual sexual acts between residents and could not provide documentation of consent, resulting in a failure to prevent sexual abuse.
A resident with cognitive impairment and multiple diagnoses received PRN lorazepam for anxiety without a stop date or required physician reevaluation after 14 days, contrary to facility policy. Both the LVN and DON confirmed the absence of timely review and documentation for continued use of the medication.
A resident with severe cognitive impairment exhibited a behavioral change by screaming at another resident, which was not documented or addressed by staff. This lack of intervention led to a subsequent incident where another resident, who had moderate cognitive impairment and physical limitations, struck the first resident in the face, causing injury. Staff were aware of the behavioral issues but did not report or document them, and the DON confirmed that required procedures for change of condition and care planning were not followed.
Surveyors found that a resident did not receive appropriate care for bowel/bladder continence or incontinence, catheter management, and UTI prevention. The facility failed to provide adequate attention to continence needs, proper catheter care, and sufficient infection control measures.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A deficiency was cited when a resident's care plan did not address all of their needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
Two residents were not provided care in a manner that promoted dignity and respect, as required by facility policy. One resident, dependent on staff for daily activities, was dressed in a hospital gown instead of personal clothing without being given a choice. Another resident, also fully dependent, was observed with food debris around the mouth and a stained gown, with staff acknowledging the lack of cleanliness. These actions did not align with the facility's stated commitment to resident dignity and well-being.
Two residents with complex medical needs did not have accurate or comprehensive care plans addressing their specific medical devices. One resident's care plan incorrectly referenced a shunt instead of a central venous catheter for dialysis, while another resident with a heart monitor (Zio Patch) had no care plan interventions for device care or monitoring. Nursing staff and the MDS nurse confirmed these omissions, and the facility's policy requiring updated, individualized care plans was not followed.
Two residents were administered medications not in accordance with prescriber orders, resulting in a medication error rate above 5%. One resident received carvedilol without food, and another received sevelamer without a meal present, despite both medications being ordered to be given with food. Nursing staff confirmed the deviations from orders, and facility policy requires medications to be administered as prescribed.
Three unidentified loose pills were found on the floor of the medication storage room, and staff interviews confirmed that this was not in accordance with facility policy, which requires discontinued medications to be placed in a secure container for destruction. The pills were not identified, and staff acknowledged the risk of them being accessed outside the medication room.
Surveyors found that kitchen staff did not label food items in refrigerators and freezers with required information such as open dates and use by dates, and failed to discard expired pudding cups. Staff acknowledged these oversights, which were not in accordance with facility policy and could have led to unsafe food being served.
A resident with cancer and visual impairment, who was cognitively intact, repeatedly requested assistance to complete an Advance Directive but did not receive the necessary help from staff for seven years. The Social Services Worker failed to communicate with the Ombudsman and incorrectly believed the resident needed a designated decision-maker, resulting in the resident's wishes not being formally documented. Facility policy required staff to assist with advance directives, but this was not followed.
A resident with multiple complex medical conditions experienced eight episodes of low blood pressure while on antihypertensive medication. Despite reporting symptoms of syncope and having medication held due to low readings, the physician and responsible party were not notified, and no change of condition was documented by nursing staff, contrary to facility policy and standard practice.
A resident with a history of stroke and documented contractures in the left upper and both lower extremities was inaccurately assessed on the MDS, which failed to reflect any impairment in range of motion despite clear evidence from medical records and direct observation. The MDS nurse acknowledged the oversight, and the facility's policy requiring thorough assessments was not properly followed.
A resident with dementia and other medical conditions, who was dependent on staff for daily activities, did not receive regular oral care as required. Observations showed poor oral hygiene, and both the resident and a CNA confirmed that oral care was not provided consistently. Facility policy required staff to assist with oral hygiene, but this was not done.
Two residents did not receive their prescribed medications with food or meals as ordered by their physicians. One resident was given carvedilol without food, and another received sevelamer after eating, rather than with a meal. Nursing staff confirmed the medications were not administered according to orders, and facility policy requires medications to be given as prescribed.
A resident with chronic medical conditions and intact cognition experienced ongoing mouth pain and difficulty chewing due to the facility's failure to follow up on a dental consult and assist with obtaining dentures. Despite multiple requests and a care plan intervention for dental evaluation, the resident was overlooked for several months, leading to frustration and unmet dental needs.
A resident with multiple medical conditions and intact cognition repeatedly received meals that were unappetizing and did not align with his stated preferences, including overcooked vegetables and dry meats. Despite voicing his concerns to dietary staff, the facility did not consistently accommodate his food preferences, resulting in the resident refusing to eat and experiencing negative psychosocial effects.
A resident with multiple diagnoses and orders for adaptive feeding equipment was not allowed to use a weighted spoon and plate guard for self-feeding during a meal. Instead, a staff member used the specialized utensils to feed the resident directly, contrary to physician orders and the care plan, which specified these devices to promote independence. Staff interviews confirmed the equipment was present but not used by the resident as intended.
Staff did not follow the facility's infection control policy when providing wound care to a resident on enhanced barrier precautions. During a wound dressing change, a RN and a CNA failed to wear required PPE, including gown, gloves, and mask, despite the resident's need for such precautions due to a wound. This lapse was confirmed by another RN and the DON, both of whom stated that EBP should have been implemented during direct care.
A resident with significant physical impairments and dependence on staff for daily activities was observed lying in bed with the call light on the floor and out of reach. Staff interviews and review of the care plan and facility policy confirmed that the call light should have been within the resident's reach, but this was not followed.
A resident assessed as high risk for elopement, with a history of substance abuse and mobility issues, was allowed to leave the facility on an unsupervised out on pass without a specific care plan or clear supervision guidelines. When the resident did not return as expected, staff failed to initiate a search or notify the DON, administrator, or authorities in a timely manner, and did not follow established elopement risk procedures, resulting in a prolonged period before the resident was reported missing.
A resident with alcohol use disorder and psychoactive substance abuse did not receive a person-centered care plan or behavioral health services, including counseling or referral to a psychologist. The facility allowed the resident to leave on pass without clear supervision guidelines, and staff confirmed that no care plan or interventions were developed to address the resident's substance use, contrary to facility policy.
A resident with severe cognitive impairment and a history of aggression was inadequately supervised while wandering the facility, resulting in the resident entering another's room and scratching a fellow resident's face. Staff interviews revealed that the incident occurred when the CNA briefly looked away, and that closer monitoring and redirection could have prevented the altercation. Facility policies require monitoring of residents with dementia and protection from abuse, but these were not effectively implemented, leading to a deficiency.
The facility did not follow its Enhanced Barrier Precaution policy, as a CNA failed to wear an isolation gown during high-contact care with a resident on EBP. Additionally, isolation gowns were unavailable in three EBP rooms, as confirmed by staff. This deficiency increased the risk of cross-contamination and infection spread.
A facility failed to document a resident-initiated discharge, leading to potential confusion among the healthcare team. The resident, with multiple medical conditions, was evacuated due to a fire and later expressed a desire to move closer to friends and doctors. Staff interviews revealed a lack of documentation regarding the discharge process, contrary to facility policy.
A resident with functional quadriplegia reported an alleged abuse incident involving aggressive handling by staff, resulting in pain in the resident's left hand. The facility failed to report the allegation within the required two-hour timeframe to the local police, state survey agency, and ombudsman. The charge nurse reported the incident to the Social Services Worker eight hours after it was initially reported by the resident, contrary to the facility's policy requiring immediate reporting.
Failure to Develop Individualized Care Plans for Medications, Activities, Equipment, and Fluid Restriction
Penalty
Summary
The facility failed to develop individualized, resident-centered care plans for four sampled residents. The report states that Resident 73, who was admitted with muscle weakness and a stage 4 sacral pressure ulcer, was observed lying on a low air loss mattress, but the care plan review showed no care plan for the use of the mattress. Staff stated that a care plan should have been in place to monitor the mattress use, determine whether interventions were effective, and ensure proper use to support wound prevention and healing. Resident 22, who had diagnoses including COPD, CHF, and cardiomegaly, was ordered montelukast (Singulair). The medication regimen review identified montelukast and noted the need to monitor for black box warning side effects and to include those behaviors in the care plan. However, the resident’s care plans did not include monitoring for the black box warning side effects of montelukast. Staff stated that a care plan should have been developed for black box warning monitoring to prevent serious side effects. Resident 35, who had diagnoses including encounter for attention to gastrostomy, DM, and osteoarthritis, had an activity assessment showing adequate vision and hearing, with interests in music, watching TV, and talking/conversing. The resident was observed in the room asleep in bed with no TV or radio present, and the care plan review showed no activity care plan. Staff stated the resident should have had a care plan identifying specific activities, including in-room activities such as TV or radio for music and talking/conversing. Resident 16, who had DM and ESRD and was on dialysis, had a fluid restriction order of 1,000 cc per day. Multiple observations showed full cups of water and a bottle of soda at the bedside, and staff stated the resident was noncompliant by keeping more than the prescribed amount of fluid at the bedside. The electronic chart did not contain a care plan for this noncompliance, and staff stated a care plan should have been developed to address the behavior.
Failure to provide ADL assistance and nail care
Penalty
Summary
The facility failed to ensure residents maintained independence, functional status, grooming, and personal hygiene for three sampled residents. One resident with dementia, schizoaffective disorder, anxiety disorder, and severely impaired cognitive skills required partial/moderate assistance with eating and oral hygiene and substantial/maximal assistance with upper body dressing. The care plan directed staff to encourage participation in ADLs within the resident’s capability and to keep the head of bed elevated to 90 degrees for meals because of COPD-related airway clearance needs. During observation, the resident was seen eating lunch in bed without staff assistance, with the lunch tray placed across the bed on a bedside table and the head of bed positioned too low. The resident had difficulty reaching the meal. A PTA stated the head of bed was not raised to 90 degrees, and a CNA stated the resident could be left alone because the resident could eat by herself. The MDS nurse later stated the resident required partial assistance during meals and was not positioned correctly, and the PT stated proper positioning during meals was part of the care needed and helped promote easier swallowing and prevent aspiration. The facility policy for in-room meals stated the resident should be positioned as upright as possible. Two other residents were observed with fingernails that were too long and not maintained as part of grooming and personal hygiene. One resident with a history of cerebral infarction affecting the left non-dominant side, major depressive disorder, and hypertension had long fingernails on both hands during observation, and the resident stated the nails needed to be cut. A CNA and the DSD both acknowledged the nails were long and that staff needed to trim them to prevent scratching, skin breakdown, and infection. The DON stated the resident’s ADL care plan was incomplete because it did not include grooming and personal hygiene, and that fingernails should be trimmed at least twice per week. Another resident with lymphedema, bilateral lower-extremity cellulitis, gastroenteritis, and generalized muscle weakness was observed with long, jagged fingernails that were yellowish, dirty, and had blackish-brown debris under them. The resident stated the nails were long and dirty and said staff had been told previously, but the fingernail cart was not available on the weekend. On later observation, the nails remained long and dirty. A CNA and the DSD confirmed the nails were dirty, jagged, and discolored, and the DON stated the ADL care plan was incomplete because it did not include grooming or offering to cut the resident’s long fingernails. The facility’s Nail Care policy stated nail care was to promote cleanliness, safety, and a neat appearance, and the ADL policy stated residents should receive appropriate support and assistance with hygiene, mobility, and dining.
Incorrect LALM Settings for Two Residents
Penalty
Summary
The facility failed to ensure low air loss mattresses (LALMs) were set correctly for two residents according to physician orders and the mattress operator manual. Resident 35 had diagnoses including diabetes mellitus, osteoarthritis, and a gastrostomy tube, and was assessed as severely cognitively impaired and dependent for activities of daily living. Resident 35’s weight was documented as 158 lbs., but the LALM was observed multiple times set at approximately 225 lbs. The treatment nurse verified the setting was incorrect and stated the mattress setting should be based on the resident’s weight. Resident 5 was admitted with diagnoses including cirrhosis of the liver, a history of a stage II pressure ulcer of the left buttock, and anxiety disorder. Resident 5 was documented as severely cognitively impaired, dependent for multiple activities of daily living, and at risk for pressure ulcers. Resident 5’s weight was documented as 152 lbs., but the LALM was observed multiple times set at 260 lbs. Resident 5 stated the bed was hard and hurt his back a little bit. Licensed nursing staff and the registered nurse supervisor confirmed the mattress was set too firm and not according to the resident’s weight. Record review showed Resident 5’s physician order stated the resident may have an LALM for skin maintenance, and the care plan included the same intervention, but the director of nursing stated both were incomplete because they did not specify that the mattress should be set based on the resident’s weight. The facility’s air loss mattress policy stated the air pressure should be adjusted based on the resident’s weight to serve the purpose. The director of nursing stated licensed staff were not following the policy when the mattresses for Residents 5 and 35 were set incorrectly.
Failure to Provide Ordered Catheter Care and UTI Prevention
Penalty
Summary
The facility failed to provide proper indwelling catheter care and urinary infection prevention services for two residents. Resident 7 was admitted with diagnoses including urinary retention, diabetes mellitus, and bilateral below-knee amputation, and the MDS indicated the resident had independent cognition but required assistance with several activities of daily living and had an indwelling catheter. The care plan for urinary tract infection risk related to Foley catheter use called for Foley care every shift and after each bowel movement, with observation of urine output for foul odor, sediments, color, amount, abdominal pain, and distention. The physician ordered catheter care with soap and water around the urinary meatus every shift and as needed, and weekly flushing with normal saline. During observation, Resident 7's catheter tubing was seen with sediments in the dining room and again in the resident's room. The resident stated staff check and clean it sometimes. During record review and interview, the RN stated Resident 7's catheter care was not completed every shift in accordance with the physician's order, and the TAR lacked documentation for catheter care on multiple dates and shifts. The facility's policy also stated to observe urine for sediments or color changes and notify the doctor for sediments noted in the urine flow. Resident 48 was admitted and later readmitted with diagnoses including dementia, kidney disorder, ureter disorder, and UTI. The MDS indicated moderately impaired cognition and substantial assistance with toileting hygiene and bathing, and the resident also had an indwelling catheter. The order summary and care plan required catheter care every shift with cleansing around the urinary meatus using soap and water. Review of the TAR showed no catheter care documented on multiple days across May and June 2026. The treatment nurse stated the resident needed catheter care every shift to prevent UTIs and that if care was not documented, the facility could not ensure it was provided; the DON stated catheter care was important and needed every shift in accordance with the physician's order.
Dialysis care, I&O monitoring, and ordered labs not completed
Penalty
Summary
The facility failed to provide dialysis care and services in accordance with its policy for three residents receiving hemodialysis. For one resident with ESRD, anemia, and dementia, the care plan directed staff to assess the left upper arm AV shunt for redness, swelling, warmth, exudate, tenderness, bruit, thrill, and bleeding, and to document the resident’s condition before and after dialysis. The resident’s dialysis communication record showed that the AV shunt check was not completed on two post-dialysis dates and two pre-dialysis dates. During interviews, nursing staff stated the form was not filled out completely and that the access site should have been assessed and documented before leaving for dialysis and upon return. For a second resident with type 2 DM, ESRD, and dependence on renal dialysis, the care plan directed staff to monitor intake and output every shift. Review of the intake and output record and the electronic chart showed that urine output was not documented for one overnight shift. Nursing staff confirmed there was no documented urine output for that shift and that it should have been recorded per the care plan and facility policy. For a third resident with ESRD, dependence on renal dialysis, and anemia, the care plan directed staff to monitor intake and output every shift and to complete laboratory testing as ordered. Review of the records showed multiple shifts with no documented output, and the resident’s CBC and BMP were completed monthly rather than weekly as ordered. Nursing staff and the DON stated the resident should have had I&O monitoring every shift and weekly labs completed as ordered, and that the order should have been followed or clarified with a new order.
Failure to Maintain Resident Dignity and Timely Meal Service
Penalty
Summary
The facility failed to promote dignity and respect for two residents. Resident 71 had diagnoses including hemiplegia, hemiparesis, cerebral infarction affecting the left non-dominant side, dysphagia, diabetes mellitus, and hypertension, and the MDS indicated severely impaired cognitive skills for daily decision making and dependence or substantial assistance with multiple activities of daily living. During an observation in the dining room, Resident 71 was sitting in a wheelchair at the back of the room, drooling onto the resident’s shirt and holding a rolled hand towel on the contracted left hand. The LVN stated the shirt was already wet from drool, and the resident’s lunch tray was not on the table while other residents were already eating. On another observation in the hallway, Resident 71 was sitting in a wheelchair and was drooling and dripping on the chin while visitors and residents passed by. During a concurrent interview, a CNA stated it was not okay for Resident 71 to be drooling in the hallway because of dignity and that staff needed to make sure the resident was always clean. The DSD later stated staff were not supposed to let Resident 71 drool on the shirt, particularly in the dining room and hallway, and that staff should wipe the resident’s mouth frequently to maintain dignity. Resident 72 had diagnoses including diabetes, hypertension, left foot hallux valgus, and dysphagia, and the MDS indicated intact cognitive skills for daily decision making and independence with eating. The resident reported that meal trays were repeatedly late, stating breakfast arrived at 8:05 AM and lunch was not on time. A CNA stated lunch trays began going out around 12:15 PM and Resident 72’s lunch tray was served at 12:48 PM, which was considered late. The resident later stated breakfast was received around 8 AM and lunch was received less than 10 minutes before the observation, while the CNA and DTS stated late trays could leave residents feeling hungry, angry, upset, left out, or frustrated. The DON stated breakfast mealtimes were 7:15 AM to 7:45 AM and lunch mealtimes were 12:15 PM to 12:45 PM, and acknowledged that trays served after the allotted mealtime could become cold and may feel disrespectful to residents.
Call Light Not Within Reach for Resident in Bed
Penalty
Summary
The facility failed to ensure the call light was within reach for one resident, who was admitted with diagnoses including muscle weakness, HIV, and dementia. The resident's MDS dated 4/14/2026 indicated severely impaired cognitive skills for daily decision making and dependence for toileting hygiene, showering, lower body dressing, and putting on/taking off footwear, with substantial assistance needed for upper body dressing and personal hygiene and partial assistance needed for eating and oral hygiene. During an observation in the resident's room on 6/23/2026, the resident was lying in bed and stated that he could not find his call light. At the same time, the call light was observed tucked behind his back. A CNA stated that the call light was tucked under the resident's back and that if he could not locate it, he would be unable to call for help when in distress. The CNA also stated the resident could experience a medical emergency, such as difficulty breathing, and would not receive timely assistance if the call light was not within reach. The DON reviewed the facility's Call Light/Bell policy, which states the call light is to be immediately within reach when a resident is in bed, and confirmed that the policy requires the call light to be in reach while the resident is in bed.
Unclean and Cluttered Resident Room During Meal
Penalty
Summary
The facility failed to provide a clean, comfortable, sanitary, and homelike environment for Resident 57. Resident 57 was admitted with diagnoses including dementia, schizoaffective disorder, and anxiety disorder, and the MDS dated 6/13/2026 indicated severely impaired cognitive skills for daily decision making. The MDS also showed the resident required partial/moderate assistance with eating and oral hygiene, substantial/maximal assistance with upper body dressing, and was dependent for toileting, showering, lower body dressing, and putting on/taking off footwear. During dining observation on 6/23/2026 at 1:35 PM, Resident 57 was sitting in a wheelchair watching TV with a lunch tray on a bedside table in front of the resident. A pillow and clothes were observed on the floor near a trash can, a used/soiled diaper with pants was on the floor in front of the wheelchair, and a green hairbrush was on the lunch tray. The resident’s care plan included an intervention to provide a safe and uncluttered environment, and the care plan for schizoaffective disorder included monitoring behavior of throwing food and utensils at staff/floor every shift. Staff interviews stated the room should have been clean, sanitary, clutter free, and homelike, and that Resident 57 was not provided a clean and homelike environment during the meal.
Delayed Podiatry Consultation
Penalty
Summary
The facility failed to provide podiatry services for a resident whose care plan included a podiatry consult as needed. The resident was admitted with diagnoses including lymphedema, bilateral lower-extremity cellulitis, gastroenteritis, and generalized muscle weakness. The MDS indicated the resident had moderately impaired cognitive skills for daily decision making and required assistance with multiple activities of daily living, including lower body dressing, putting on and taking off footwear, toileting hygiene, bathing, and transfers. During observation, the resident was sitting up in bed and showed both lower extremities, which had thick, yellowish toenails on both feet. The resident stated he wanted to see a podiatrist to have his feet checked and toenails cut because they were long, thick, and growing upward, and he could not reach them. The resident stated a podiatrist visited the facility, but the podiatrist saw the roommate and did not speak with him. The resident also stated he asked RNS 2 if the podiatrist could speak with him, but was told no. RNS 2 stated the podiatrist came to the facility and that the resident asked her to request a visit, but the resident was not on the list of residents scheduled to be seen. RNS 2 stated she did not endorse the request to the next shift, did not inform the resident that he was not included on the podiatry list, did not document the request in the communication book, and did not initiate a podiatry consultation or follow up with SSD. The DON reviewed the care plan and stated licensed staff should have left a follow-up note for SSD so the resident could be seen by the podiatrist without delay. The DON also stated there was a miscommunication among staff that resulted in a delay in podiatry services and negatively affected the resident's emotions and self-esteem.
Incorrect Oxygen Setting and Incomplete Monitoring Documentation
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for one resident who was admitted with cirrhosis of the liver, a history of a stage II pressure ulcer of the left buttock, and anxiety disorder. The resident’s MDS indicated severely impaired cognitive skills for daily decision making and dependence in multiple activities of daily living. The physician’s order dated 4/1/2026 directed oxygen at 2 liters per minute via nasal cannula continuously for shortness of breath and respiratory distress, with titration up to 5 liters per minute via nasal cannula or mask, and oxygen saturation monitoring if greater than 92% every shift. During observation, the resident was sleeping in the room while using an oxygen concentrator that was set at more than 5 liters per minute via nasal cannula. A concurrent observation and interview with an LVN confirmed the oxygen machine was set above 5 liters per minute and was beeping with an orange light on. The LVN stated the resident’s oxygen level was higher than 5 liters per minute. Later interviews with the LVN, an RN supervisor, and the DON confirmed the oxygen setting was incorrect and above 5 liters per minute. Record review showed the TAR lacked documentation of oxygen saturation and the level of oxygen administered every shift on multiple dates, and the DON stated the licensed staff should have been monitoring and documenting oxygen saturation and oxygen level every shift. Review of the care plan for continuous oxygen therapy showed it did not include goals and interventions for assessments, monitoring signs and symptoms of respiratory distress, monitoring oxygen saturation every shift, or checking the oxygen setting. The facility’s oxygen administration policy required recording the oxygen flow rate, route, rationale, frequency, duration, and assessment data before, during, and after the procedure, and the DON stated the staff did not follow the policy because the required monitoring and documentation were missing.
Medication Administration Not Given as Ordered
Penalty
Summary
Pharmaceutical services were not provided in accordance with physician orders and the facility’s medication administration policy for two residents. One resident had diagnoses of type 2 DM, major depressive disorder, and epilepsy, and the MDS indicated intact cognitive skills but dependence for multiple activities of daily living. The physician’s orders and MAR showed Keppra 750 mg, Lexapro 10 mg, and metformin 500 mg were scheduled for 9 AM each day. During a concurrent observation and interview, an LVN was observed preparing to administer the resident’s Keppra, Lexapro, and metformin at 10:12 AM and stated the medications were due at 9 AM but would be given late. The LVN stated medications can be given one hour after they are due and that it had been over an hour since the medications were due. The LVN also stated that medications would not treat the resident’s conditions effectively if given late. The DON later reviewed the facility’s medication administration policy, which stated medications must be administered within one hour before or after the ordered time, and stated medications must be administered at the latest one hour after they are due. A second resident had diagnoses including muscle weakness, HTN, and ASHD, and the MDS indicated modified independence with cognitive skills for daily decision making. The physician order for metoprolol ER 25 mg specified it was to be given by mouth once daily for HTN and with breakfast. During observation, an LVN administered the metoprolol at 9:44 AM without breakfast or any food. The LVN stated she did not give the medication with the breakfast meal and did not offer food or a snack. RN and RNS interviews confirmed the medication was not given with breakfast as ordered, and the facility policy stated medications are to be administered following the scheduled medication administration routine unless otherwise specified by the doctor.
Pharmacist Review Failed to Identify Medication Monitoring and Indication Issues
Penalty
Summary
The facility failed to ensure a licensed pharmacist completed and followed up on medication regimen review irregularities for two sampled residents. The report states that the facility’s Medication Regimen Review process was intended to identify medication-related problems, including inadequate monitoring and medications without adequate indication, and that the Black Box Warning policy required safe drug prescribing and administration. During record review and interviews, the Director of Nursing confirmed that pharmacist recommendations related to black box warning monitoring were expected to be followed. For one resident with COPD, CHF, and cardiomegaly, the order summary showed montelukast was prescribed, and the pharmacist’s medication regimen review identified that the resident required monitoring for a black box warning and that this monitoring should be addressed in the care plan. However, during review of the resident’s care plans with the Registered Nurse Supervisor, no care plan was found for monitoring the black box warning side effects of montelukast. The RN stated the resident should have had a care plan for black box warning monitoring. For another resident with dementia, schizoaffective disorder, and anxiety disorder, the order summary showed donepezil HCL was ordered for cognitive impairment. The resident’s MDS identified dementia, and staff confirmed the diagnosis listed for donepezil was incorrect because it should have been dementia rather than cognitive impairment. The consultant pharmacist reviewed the resident’s medications but made no recommendation to clarify the order, and both nursing staff and the pharmacist stated that the order should have been clarified to reflect dementia as the indication.
Incorrect indication documented for donepezil order
Penalty
Summary
The facility failed to ensure that one sampled resident was free from an unnecessary drug because the resident’s donepezil hydrochloride order did not list an accurate indication for use. Resident 57 was admitted with diagnoses including dementia, schizoaffective disorder, and anxiety disorder, and the MDS indicated severely impaired cognitive skills for daily decision making, along with extensive assistance needs for activities of daily living. The order summary showed donepezil hydrochloride 5 mg at bedtime ordered for “cognitive impairment.” During record review and interviews, RN 2 and RNS 1 both verified the order and stated that the indication was incorrect and should have been dementia rather than cognitive impairment. The facility policy on unnecessary drugs stated that medications should be carried out with dosage, route, frequency, and diagnosis to justify medication use.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent. Surveyors identified 4 medication errors out of 27 observed medication administration opportunities, resulting in an overall error rate of 14.81 percent for two sampled residents. The errors involved Resident 23 and Resident 2 during observed medication administration and record review. Resident 23 had diagnoses including type 2 diabetes, major depressive disorder, and epilepsy. The physician's orders showed Keppra 750 mg twice daily, Lexapro 10 mg daily, and metformin 500 mg daily, all scheduled for 9 AM. During a concurrent observation and interview, LVN 3 was preparing to administer these medications at 10:12 AM and stated they were due at 9 AM but would be given late. LVN 3 stated medications can be given one hour after they are due and that it had been over an hour since the medications were due. The DON later confirmed the facility's medication administration policy required medications to be given within one hour before or after the ordered time. Resident 2 had diagnoses including muscle weakness, hypertension, and atherosclerotic heart disease. The physician's order for metoprolol extended release 25 mg specified that it be given by mouth once daily for hypertension, hold for systolic blood pressure less than 110 and heart rate less than 60, and give with breakfast. During observation, LVN 2 administered metoprolol at 9:44 AM without breakfast or any food. LVN 2 stated she did not give the medication with breakfast and did not offer food or a snack. RN 2 and the RNS stated the medication should have been given with breakfast, and the facility policy indicated medications were to be administered following the scheduled routine unless otherwise specified by the doctor.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to follow its medication administration policy for two sampled residents during observed medication passes. Resident 23 had diagnoses including type 2 DM, major depressive disorder, and epilepsy, and the MDS indicated intact cognitive skills but dependence for multiple activities of daily living. The physician’s orders and MAR showed Keppra 750 mg twice daily, Lexapro 10 mg daily, and metformin 500 mg daily were all scheduled for 9 AM. During a concurrent observation and interview, an LVN was observed preparing to administer these medications at 10:12 AM and stated they were due at 9 AM but would be given late, explaining that medications can be given one hour after they are due and that more than an hour had already passed. Resident 2 was also affected by a medication administration error involving metoprolol. The report states that LVN 2 failed to administer metoprolol with breakfast as ordered on 6/25/2026. The facility’s P&P, reviewed with the DON, stated medications must be administered within one hour before or after the ordered time, and the DON stated medications must be given no later than one hour after they are due. The DON also stated that delayed administration could affect control of a resident’s medical conditions, including DM, epilepsy, and depression.
Incomplete Documentation for Low Air Loss Mattress Use
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one sampled resident who was admitted with muscle weakness and a stage 4 pressure ulcer of the sacrum. The resident’s MDS dated 5/26/2026 showed intact cognition, dependence for showering, toileting hygiene, lower body dressing, and footwear, supervision for eating and oral hygiene, and substantial assistance for upper body dressing, but it did not indicate use of a pressure reducing device for the bed. During observation on 6/23/2026, the resident was seen in the room on a low air loss mattress (LALM), and an LVN stated the resident was on a LALM. Review of the order summary report and nursing progress notes showed no order for the LALM and no documentation that it was being used, although the LVN stated the resident was using one. The DON reviewed the facility’s policy on air loss mattresses and stated that a physician order was required for LALM use, and also reviewed the physician orders policy stating that orders must be obtained before initiating treatment and must be specific and complete. The DON stated the LALM should have been ordered before use and documented in the resident’s medical record.
Infection Control Lapses During Meal Assistance and G-Tube Feeding
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff did not follow infection prevention measures for two residents. During meal assistance with a resident who had severely impaired cognitive skills and required partial moderate assistance with eating and oral hygiene, a CNA was observed moving her eyeglasses from her face to her head and back without performing hand hygiene before handling the resident’s food tray and removing the lid and saran wrap from the resident’s drinking cups. The CNA stated she should have performed hand hygiene after touching her eyeglasses and before assisting the resident, and said hand hygiene is important for infection control to prevent infections or illness from bacteria that may spread. A second deficiency involved a resident with dysphagia, CKD, COPD, severely impaired cognitive skills, dependence for personal care, and a feeding tube. The resident had a physician’s order for Jevity 1.2 cal via G-tube at 60 ml/hour for 20 hours. During observation at the bedside, the resident’s G-tube pump was seen with dried tan drops on the top and sides of the machine. The RN supervisor stated the pump had dried stains, the same color as the resident’s Jevity feeding, and that the pump should not have stains. The DON stated staff need to maintain cleanliness of the G-tube pump to prevent cross contamination from the dirty pump into the feeding and/or GT site of the resident. The facility’s policy for enteral nutrition indicated the pump and pump stand should be kept clean by washing with a cloth and nonstaining germicidal agent. The facility’s food handling policy indicated food should be stored, prepared, handled, and served so the risk of foodborne illness is minimized.
Inaccurate Documentation of Controlled Substance Administration and Narcotic Count
Penalty
Summary
The facility failed to maintain clinical records in accordance with professional standards and its own policies for one resident by not accurately documenting the administration of a controlled substance in the narcotic count record. The resident was admitted with diagnoses including a right shoulder rotator cuff tear, anxiety, and depression, and the MDS dated 4/16/2026 indicated moderate cognitive impairment, substantial/maximal assistance with several activities of daily living, partial/moderate assistance with others, scheduled and as-needed medications, and occasional pain. A physician order dated 4/3/2026 directed Oxycodone HCL 5 mg by mouth every 6 hours as needed for pain rated 5-10/10 unrelieved by non-opioids. On 5/5/2026, the MAR showed the Oxycodone HCL was not given, but during a concurrent observation of the narcotic count, LVN 1 stated the count was incorrect and there was a discrepancy from the morning count, with 18 tablets observed in the bubble pack when the narcotic sheet indicated 19 should remain. The DON also stated the count did not match and one tablet was missing. The resident stated he received his Oxycodone around 6:00 a.m. from a male nurse, and LVN 2 later stated he gave the medication at 6:00 a.m. but forgot to document it in the MAR and narcotic sheet. The DON stated LVN 2 should have documented the medication administration in both records, and the facility's policies required immediate charting after administration, accurate and timely documentation, and shift-to-shift controlled drug counts documented in the controlled drugs-count record.
Failure to Reconcile Hospital Discharge Orders for Long-Acting Insulin
Penalty
Summary
The facility failed to reconcile and implement a General Acute Care Hospital (GACH) discharge medication order for long-acting insulin (insulin glargine) for one resident with type 2 diabetes mellitus, ESRD, and COPD. The GACH Discharge Medications List dated 2/23/2026 included an order for insulin glargine 20 units subcutaneously every 24 hours. Upon readmission on 3/14/2026, the facility’s admission process did not carry out this long-acting insulin order. The resident’s Order Summary as of 3/15/2026 showed only an order for insulin lispro 9 units subcutaneously before meals, with no long-acting insulin ordered. The facility’s P&P for Admission required the licensed nurse to notify the physician of admission and verify transfer and admission orders, and the Medication Administration P&P required drugs to be administered in accordance with written physician orders. The resident reported having taken long-acting insulin for more than 20 years and stated that at home he used both long-acting and short-acting insulin based on blood sugar results. He stated that in the facility he was only receiving short-acting insulin before meals after staff checked his blood sugar, and that long-acting insulin was started only days after his readmission. Review of the March and April 2026 MARs with RN 1 confirmed there was no order for insulin glargine from admission on 3/14/2026 until 4/17/2026, despite RN 1 observing consistently high blood sugars on the EMAR. The DON confirmed that the GACH discharge order for insulin glargine was not carried out upon admission and acknowledged that the admitting nurse did not completely follow the GACH Discharge Medications List. As a result of this failure, the resident experienced hyperglycemia and was transferred to the GACH on 4/10/2026, placing the resident at risk for DKA, dehydration, confusion, and coma.
Failure to Timely Administer Ordered IV Hydration
Penalty
Summary
The facility failed to administer ordered IV hydration as prescribed for one resident. The resident had diagnoses including malignant neoplasm of the lungs and bones, neoplasm-related pain, and malnutrition, and required varying levels of assistance with activities of daily living, including partial/moderate assistance with eating and oral hygiene and dependence for toileting, showering, lower body dressing, and footwear. A physician’s order dated 4/10/2026 directed that the resident receive peripheral IV hydration with normal saline over four hours on 4/10/2026, 4/11/2026, and 4/12/2026. However, the IV hydration ordered for 4/10/2026 was not administered on that date. During record review and interview on 4/23/2026, an RN reported that when she began her 7 AM–3 PM shift on 4/11/2026, it had been endorsed to her that the IV hydration order from the previous night had not been carried out, and the resident did not have an IV line in place at the start of her shift. The RN initiated the peripheral IV line and IV hydration on 4/11/2026 at around 11 AM. The DON stated she was not aware that the IV hydration ordered for 4/10/2026 had not been administered until 4/11/2026 and noted that the IV hydration order was important because the resident had experienced hypotension on 4/9/2026. The facility’s IV policy indicated that when an IV order is received, pharmacy should be called or faxed with IV orders, and if fluids and medications are available from the emergency kit supply, infusion therapy should be initiated as ordered in a timely manner. This policy was not followed for the IV hydration ordered on 4/10/2026.
Inaccurate Neurological and Fall Risk Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and policy-compliant medical records for two residents, specifically related to fall risk assessments and neurological evaluation flow sheets. For the first resident, admitted with diagnoses including fibromyalgia, cervical disc displacement, and hypertension, the General Acute Care Hospital history and physical documented a recent fall in the shower and that the resident was alert, oriented, and able to move all extremities. The facility’s fall risk assessment for this resident showed a score of nine, categorizing the resident as low risk for falls, but key sections on ambulation/elimination status, gait/balance, and systolic blood pressure were left incomplete. RN 1 and the DON both acknowledged that these omissions meant the assessment was incomplete and that, if fully completed, the score would have been 10 or higher, indicating a high fall risk. The same resident’s Neurological Evaluation Flow Sheet dated 4/8/2026 contained multiple documentation errors and omissions. The tool included instructions for an initial neurological assessment followed by checks every 15 minutes for four times, every 30 minutes for four times, every hour for two times, and then once per shift for 72 hours, as well as specific codes to document respiratory patterns (N, BR, C, B, T, H). The flow sheet showed an initial assessment at 5:30 PM and subsequent entries at 5:45 PM, 6:00 PM, 6:15 PM, 6:30 PM, 7:00 PM, 7:30 PM, 8:00 PM, 8:30 PM, 9:00 PM, 9:30 PM, and 10:00 PM, but the 10:00 PM column had no assessment documented, and there was no documented neurological assessment at 10:30 PM despite the required hourly frequency. RN 1, RN 2, and the DON all verified that the last completed assessment was at 9:30 PM, that the 10:00 PM column was blank, and that there was no evidence of resident refusal. They also confirmed that respiratory patterns were incorrectly documented as “3/10” and “0/10” instead of using the required letter codes, meaning the instructions on the form were not followed. For the second resident, who had diagnoses including anemia, muscle weakness, and osteoarthritis, the MDS indicated severely impaired cognitive skills for daily decision-making and varying levels of assistance needed for ADLs, as well as a history of at least one fall since admission. The resident’s Neurological Evaluation Flow Sheet from 3/19/2026 to 3/21/2026 contained instructions identical to those for the first resident regarding the use of specific letter codes to document respiratory patterns. However, the flow sheet showed the letter “R” documented in all respiratory pattern boxes over that period, even though “R” was not one of the approved codes listed in the instructions. RN 1 and the DON both confirmed that this documentation was inaccurate because it did not follow the specified coding system. The facility’s policy on charting and documentation required that medical record entries be objective, complete, and accurate, and that only facility-approved abbreviations and symbols be used, which was not adhered to in these instances. The survey findings concluded that these failures in documentation for both residents—leaving required sections of the fall risk assessment incomplete, omitting required neurological checks, and using non-approved or incorrect notations for respiratory patterns—did not comply with the facility’s charting and documentation policy. The report stated that this deficient practice had the potential to result in miscommunication, improper delivery of care, and inaccurate information about the care provided to the residents.
Inaccurate Reporting and Incomplete Investigation of Suspected Contraband
Penalty
Summary
The facility failed to provide an accurate report detailing the suspected presence of contraband for one resident. The resident was admitted with diagnoses including fibromyalgia, cervical disc displacement, and hypertension, and was documented as alert and oriented with full movement of extremities per a recent hospital H&P. On admission, the resident’s belongings list noted that the resident did not allow a CNA to check a black purse. Later, during the night shift, the CNA providing care found a semi-clear, hard substance stuck to the resident’s right lower back and believed it to be cracked menthol candy. After the resident’s death, an LVN located a container with a hard semi-clear substance in the resident’s belongings while looking for family contact information and showed it to staff; the CNA reported that the substance in the container resembled what she had found on the resident’s body. The facility’s initial report to the state agency stated that a police officer instructed staff not to touch the resident’s belongings and that the officer found a small container with an unknown substance. However, the police report documented that facility staff had located apparent methamphetamine in the resident’s backpack and that the LVN had unzipped the backpack and pointed out a clear container with a white crystalline substance, which the officer then picked up. In an interview, the LVN acknowledged that he, not the police officer, found the container and that he had reported this incorrectly to the administrator and DON, initially stating that the police officer found it. The LVN also stated he did not report the CNA’s observation of a similar substance on the resident’s skin to the administrator or DON. The DON later stated that the facility’s investigation and report were based solely on the LVN’s initial account, that the CNA assigned to the resident was not interviewed, and that the resulting investigation was inaccurate and confusing due to missing information. This sequence of events did not comply with the facility’s policies requiring immediate reporting to administration and a written report accurately detailing the incident and subsequent actions.
Failure to Administer and Monitor Medications According to Policy
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with its own policies and physician orders for two residents. For the first resident, who had multiple diagnoses including schizoaffective disorder, hyperlipidemia, major depressive disorder, and GERD, the facility did not administer eight scheduled morning medications within the required time frame. The medications, which included anticoagulants, antidepressants, antipsychotics, and other essential drugs, were due at 9AM but were not given until 11:03AM. The nurse confirmed that the medications were overdue and acknowledged that they should have been administered within one hour before or after the scheduled time. The resident also reported receiving medications late. For the second resident, who had diagnoses including benign prostatic hyperplasia, GERD, and chronic venous hypertension, the facility also failed to administer morning medications on time. The resident's 9AM medications were given at 10:30AM, and the nurse left the medications unattended on the resident's bedside table. The resident was observed taking the medications at 11:45AM, but the nurse admitted that the medications should not have been left unattended and that she did not observe the resident taking them. The DON confirmed that facility policy prohibits leaving medications unattended and requires nurses to observe residents taking their medications. The facility did not have any residents authorized to self-administer medications. The facility's policy and procedure on medication administration, last revised in July 2013, states that medications must not be prepared in advance or left unattended and must be administered within one hour before or after the scheduled administration time. Both the DON and the nurse involved acknowledged that these policies were not followed in the incidents involving the two residents.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to prevent sexual abuse between two residents in the hallway, as witnessed by staff on 12/18/2025. One resident, who had a history of cocaine dependence and moderate cognitive impairment, was observed pulling down his pants and exposing himself, while another resident, diagnosed with schizoaffective disorder and major depressive disorder, performed oral sex on him. Multiple staff members, including a dietary orientee and a CNA, witnessed the incident through a glass window and reported it to the charge nurse. The event was documented in the residents' records and confirmed through interviews with both residents and staff. Resident records indicated that one resident was considered self-responsible but had moderately impaired cognitive skills, while the other was not self-responsible and had a care plan for socially inappropriate and disruptive behaviors, including touching and kissing staff and residents. The care plan intervention was to observe the resident's behavior around others, but this was not specific enough to address the risk of sexual abuse. Prior to the incident, the resident with disruptive behaviors had also exhibited other inappropriate actions, such as throwing feces and attempting to touch or kiss others. Interviews with staff and residents revealed that the facility did not have a policy regarding consensual sexual relationships or acts between residents, nor could they provide documentation of consent for the sexual activity that occurred. The DON acknowledged that the care plan for the resident with disruptive behaviors was insufficient and not tailored to prevent sexual abuse. The facility's policy on abuse and neglect required prevention of all forms of abuse, including sexual abuse, but the measures in place were inadequate to prevent the incident between the two residents.
Failure to Review and Discontinue PRN Psychotropic Medication per Policy
Penalty
Summary
The facility failed to ensure that a resident's PRN anti-anxiety medication, lorazepam, had a stop date and was reevaluated by a physician after 14 days as required by facility policy. The physician's order for lorazepam, initiated for anxiety, irritability, and restlessness, did not specify a stop date, and there was no documented evidence of a physician reevaluation for continued use after the initial 14-day period. Both the LVN and the DON confirmed that the medication order should have been reviewed and either renewed or discontinued within 14 days, in accordance with facility policy and procedure. The resident involved had a history of encephalopathy, type 2 diabetes mellitus without complications, and anxiety disorder. Assessment records indicated moderate cognitive impairment and significant dependence on staff for daily activities, including eating, hygiene, and dressing. Despite these needs and the facility's policy requiring timely review of PRN psychotropic medications, the required physician evaluation and documentation for continued use of lorazepam were not completed.
Failure to Address Behavioral Incident Leads to Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by not addressing a significant behavioral incident and not implementing appropriate interventions. One resident, with diagnoses including dementia, schizoaffective disorder, depression, and anxiety, exhibited a change in behavior by screaming at another resident. This behavioral change was not documented, monitored, or communicated to the physician as required by facility policy, nor was it incorporated into the resident's care plan. Staff separated the residents during the incident but did not report the event to a licensed nurse or take further action. Following the unaddressed behavioral incident, another resident subsequently hit the first resident in the face, resulting in a scratch under the eye and redness on the nose. The injured resident was severely cognitively impaired and dependent on staff for most activities of daily living. The resident who struck the other had moderate cognitive impairment and physical limitations. Interviews revealed that staff were aware of the first resident's tendency to invade others' personal space but did not report or document these behaviors, assuming it was common knowledge. The Director of Nursing acknowledged that the initial behavioral incident should have been treated as a change of condition, requiring immediate communication with the physician and care plan updates. Facility policies reviewed during the investigation emphasized the need to identify, document, and manage problematic behaviors and to intervene in situations likely to lead to abuse. The lack of documentation, monitoring, and intervention after the initial incident directly contributed to the subsequent physical altercation and injury.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These deficiencies were observed through direct surveyor findings, indicating lapses in the standard of care required for residents' bowel and bladder management, catheter maintenance, and infection prevention.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Promote Resident Dignity and Respect in Personal Care
Penalty
Summary
The facility failed to promote dignity and respect for two residents by not adhering to its own policies regarding resident choice and personal care. One resident, who was moderately cognitively impaired and dependent on staff for most activities of daily living, was observed wearing a hospital gown despite having personal clothing available in their closet. The resident reported that staff did not ask for their preference and dressed them in a hospital gown for staff convenience. A Certified Nursing Assistant confirmed the resident's dissatisfaction with wearing the gown, and the facility's administrator acknowledged that staff should offer residents a choice in what to wear. Another resident, who was severely cognitively impaired and dependent on staff for all personal care, was observed with food debris around their mouth and a brown stain on the shoulder of their gown. These observations were made during two separate visits, and both a Licensed Vocational Nurse and a Certified Nursing Assistant confirmed the presence of the food debris and the stained gown. The CNA stated that it is important to keep residents clean for their well-being and appearance, especially if family visits. The facility's policy on dignity and quality of life, revised in 2022, states that each resident should be cared for in a manner that promotes their sense of well-being, self-worth, and self-esteem. The observed actions and inactions by staff, including not offering clothing choices and not maintaining personal cleanliness, were inconsistent with this policy and resulted in a failure to uphold the residents' dignity and respect.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Medical Devices
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents with specific medical devices and needs. For one resident with chronic kidney disease, anemia, and hypertension, the care plan inaccurately addressed a shunt for dialysis access, when the resident actually had a right upper chest tunneled central venous catheter. The care plan included interventions appropriate for a shunt, such as avoiding blood pressure measurements or blood draws in the shunt extremity and instructing the resident not to sleep on the side with the shunt, none of which were applicable. This inaccuracy was confirmed by both nursing staff and the MDS nurse, who acknowledged that the care plan did not reflect the correct dialysis access or the appropriate interventions required for a central venous catheter. Another resident, admitted with diagnoses including subdural hemorrhage, end stage renal disease, atherosclerotic heart disease, and atrial fibrillation, had a Zio Patch heart monitor placed by a cardiologist. Upon returning to the facility, the resident reported the presence of the device to nursing staff but did not receive any explanation or care instructions. The care plan was not updated to address the presence of the Zio Patch, and there were no interventions documented for monitoring the device, assessing skin integrity, or ensuring the device was returned as required. The MDS nurse and DON both confirmed that the care plan did not include the necessary information or interventions for the heart monitor. The facility's policy requires that comprehensive, person-centered care plans with measurable objectives and timetables be developed and implemented for each resident, and that care plans be revised as residents' conditions change. In both cases, the facility did not follow this policy, resulting in care plans that did not address the residents' actual needs or the specific care required for their medical devices.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with two medication errors identified out of 30 observed opportunities, resulting in a 6.67% error rate. The first error involved a resident with hypertension, osteoarthritis, and encephalopathy, who was ordered to receive carvedilol with food. During medication administration, the nurse gave the resident carvedilol without offering food, contrary to the prescriber's order. The nurse later confirmed that the medication was not administered with food, and the DON acknowledged the importance of following medication orders to ensure effectiveness and prevent complications. The second error involved a resident with end stage renal disease, anemia, and syncope, who was ordered to receive sevelamer with meals. During observation, the nurse administered sevelamer and other medications to the resident without a meal present at the bedside. The resident confirmed that medications were given after breakfast, but not with food. A registered nurse stated that medications ordered to be given with meals should be administered accordingly to avoid stomach upset or reduced effectiveness, and that food should be offered when administering sevelamer after breakfast is served. A review of the facility's medication administration policy indicated that drugs must be administered in accordance with the written orders of the attending physician and that all medications should be given following the scheduled administration times unless otherwise specified. The observed failures to administer medications as ordered, specifically regarding the requirement to give certain medications with food, directly contributed to the facility's medication error rate exceeding the acceptable threshold.
Failure to Properly Dispose of Discontinued Medications
Penalty
Summary
Facility staff failed to follow established policy and procedure regarding the disposal of discontinued medications, as evidenced by the observation of three unidentified loose pills found on the floor of the medication storage room. During a survey, the Infection Preventionist Nurse (IPN) confirmed the presence of these pills, which included a light purple round pill, a yellow oblong pill, and a white round pill. The IPN was unable to identify the pills and acknowledged the risk that loose pills could be inadvertently moved out of the medication room and potentially accessed by residents. Further interview with a Registered Nurse (RN) confirmed that having loose pills on the floor was unacceptable and not in accordance with facility policy, which requires discontinued medications to be disposed of in a designated container for incineration. Review of the facility's policy indicated that all discontinued or outdated medications should be placed in a secure, designated location for destruction, which was not followed in this instance.
Failure to Label and Discard Expired Food Items in Kitchen Storage
Penalty
Summary
Surveyors observed that the facility failed to follow its own food handling policies and procedures by not labeling food items in the kitchen refrigerators and freezers with the required information, such as item name, date opened, and use by date. Specifically, a 1-gallon container of Thousand Island dressing in Refrigerator #2 was found without an open date, and the staff member acknowledged it had been opened the previous day but was not labeled as required. Additionally, three cups of vanilla pudding in the same refrigerator were found with a use by date that had already passed, and a dietary staff member confirmed these should have been discarded the previous day. Further observations revealed that a tray of ice cream cups in Freezer #2 lacked any labeling or use by dates, with staff confirming that dates should have been present to ensure safe service. Review of the facility's policy and procedure on labeling and dating of foods confirmed that all food items in storage, refrigerators, and freezers must be labeled and dated, and that prepared foods must be covered, labeled, and dated. These failures to adhere to policy had the potential to expose residents to pathogens due to improper food handling.
Failure to Assist Resident with Advance Directive Completion
Penalty
Summary
The facility failed to follow up on a resident's request to formulate an Advance Directive, resulting in a delay of seven years in addressing the resident's wishes. The resident, who had a diagnosis of malignant neoplasm of the right breast and blindness in one eye, was cognitively intact and required assistance with several activities of daily living. Upon admission and during subsequent care plan meetings, the resident expressed a desire to execute an Advance Directive but needed help completing the form due to her visual impairment. Despite these requests, the necessary assistance was not provided. Documentation in the resident's records, including the Minimum Data Set and care plan, indicated that the resident was capable of making her own decisions and had specifically requested CPR in the event of an emergency but did not want to be transferred to a hospital. The Social Services Worker acknowledged the resident's request but failed to communicate with the Ombudsman, who could have assisted in completing and witnessing the Advance Directive. The Social Services Worker incorrectly believed that the lack of a designated decision-maker, such as a child, prevented the resident from completing the document, and did not take further action. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that the resident was eligible to complete an Advance Directive and that the facility's policy required staff to offer assistance in establishing such directives. The policy also required regular review of advance directives and documentation of offers to assist residents. However, these procedures were not followed in this case, resulting in the resident's wishes not being formally documented for an extended period.
Failure to Notify Physician of Repeated Hypotensive Episodes
Penalty
Summary
The facility failed to notify the physician of significant changes in condition for a resident who experienced eight episodes of hypotension related to the use of Losartan Potassium-HCTZ. Despite the resident having a history of subdural hemorrhage, syncope, end stage renal disease requiring dialysis, atherosclerotic heart disease, and atrial fibrillation, there was no documentation that the physician or the resident's responsible party was notified of these repeated low blood pressure readings. The medication order specifically instructed staff to hold the medication if the systolic blood pressure was less than 110 mmHg, which occurred on multiple occasions. The resident reported experiencing syncope both during dialysis treatments and while in bed at the facility, and attributed these symptoms to the new blood pressure medication. The resident communicated these symptoms to the LVN, who confirmed that the medication was held on several dates due to low blood pressure readings. However, the LVN did not notify the physician or the responsible party, nor did she document a change of condition in the medical record regarding these hypotensive episodes. The DON stated that any deviation from a resident's baseline blood pressure, especially when accompanied by symptoms such as syncope, should be reported to the physician and documented as a change of condition. The facility's policy required that sudden or serious changes in a resident's condition be communicated to the physician prior to the end of the assigned shift. Despite these requirements, there was no evidence that the physician was notified or that appropriate documentation was made for the resident's repeated episodes of hypotension and related symptoms.
Inaccurate MDS Assessment of Range of Motion
Penalty
Summary
The facility failed to ensure an accurate assessment of range of motion (ROM) for a resident with a history of cerebrovascular accident (CVA) and documented contractures in the left upper and bilateral lower extremities. Despite multiple records, including the admission nursing assessment and history and physical, indicating the presence of contractures, the Minimum Data Set (MDS) assessment did not reflect any impairment in the resident's functional limitation in ROM. The MDS nurse acknowledged that the MDS was inaccurately completed and should have indicated impairment on one side. Observations of the resident confirmed visible contractures and functional limitations, such as the left upper extremity being contracted and the resident's inability to use the left hand due to weakness. The resident also reported numbness and required assistance with repositioning. The facility's policy required comprehensive assessments of residents' physical needs upon admission and at regular intervals, but this process was not followed accurately in this case, resulting in an incomplete and inaccurate MDS assessment.
Failure to Provide Oral Hygiene Assistance to Dependent Resident
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living, specifically oral care, to a resident who was unable to perform these tasks independently. The resident, who had diagnoses including dementia, type 2 diabetes mellitus, and gastroesophageal reflux disease, was assessed as cognitively impaired and dependent on staff for transfers and daily decision-making. Despite these needs, the resident did not receive regular oral hygiene care as required. Observations revealed the resident had visible signs of poor oral hygiene, including drooling, dried and cracked lips, a yellow patch on the tongue, and yellowish teeth. The resident reported not receiving daily oral care since admission. A CNA confirmed that oral care was not provided regularly, and the DON acknowledged that daily oral hygiene is necessary to prevent oral health problems. Facility policy also required staff to assist residents with oral hygiene, but this was not followed for the resident in question.
Failure to Administer Medications as Ordered with Food or Meals
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and facility policy for two of seven sampled residents. For one resident with a diagnosis of hypertension, osteoarthritis, and encephalopathy, the physician's order specified that carvedilol should be administered with food. During a medication administration observation, the nurse gave the resident carvedilol along with other medications but did not provide food at the time of administration. The nurse later confirmed that the medication was not given with food as ordered. For another resident with end stage renal disease, anemia, and syncope, the physician's order required sevelamer to be administered with meals. During observation, the nurse administered sevelamer and other medications in the resident's room without a meal present. The resident later stated that he had eaten breakfast earlier and received his medications almost an hour after eating. The nurse confirmed that medications ordered to be given with meals should be administered accordingly to ensure effectiveness and prevent stomach upset. A review of the facility's policy indicated that drugs must be administered in accordance with the written orders of the attending physician. The failure to administer medications as ordered, specifically with food or meals, was confirmed through observation, record review, and staff interviews.
Failure to Assist Resident in Obtaining Dental Services
Penalty
Summary
The facility failed to assist a resident in obtaining necessary dental services, specifically dentures, despite multiple requests and documented needs. The resident, who had diagnoses including cerebral infarction, anxiety disorder, and chronic pain syndrome, was cognitively intact and expressed ongoing mouth pain and difficulty chewing food. The resident's care plan included interventions for dental evaluation and intervention as needed, and a dental consult was ordered. However, the Social Service Director (SSD) did not follow up with the dental office regarding the resident's eligibility for dental services, resulting in the resident being overlooked for several months. Interviews revealed that the resident repeatedly asked staff for assistance in obtaining dentures but did not receive the necessary support. The SSD acknowledged that the resident was on a list to be checked for dental eligibility but was inadvertently missed. The facility's policy required social services to assist residents with dental appointments and arrangements, but this was not followed in the resident's case. As a result, the resident experienced frustration and continued difficulty with oral health needs.
Failure to Provide Palatable and Preferred Meals
Penalty
Summary
The facility failed to provide palatable and attractive food in accordance with its own policies for one resident. The resident, who had diagnoses including morbid obesity, GERD, and major depressive disorder, was cognitively intact and able to express his preferences and needs. Documentation and interviews revealed that the resident frequently received meals that were unappetizing, with food described as dry, mushy, and visually unappealing. The resident repeatedly voiced dissatisfaction with the taste and texture of the food, specifically noting that vegetables were overcooked and meats were excessively dry, leading him to avoid eating the meals provided. Despite the resident's clear communication of his food preferences and repeated requests for alternatives, the facility did not consistently accommodate these needs. Dietary staff acknowledged the resident's particular preferences and his tendency to refuse food that did not meet his standards, yet the issues persisted. Facility policy required that individual food preferences be accommodated within reason, but observations and interviews confirmed that the resident continued to receive meals he found unacceptable, negatively impacting his willingness to eat and his psychosocial well-being.
Failure to Ensure Resident Use of Adaptive Feeding Equipment
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, osteoarthritis, and schizophrenia, who was dependent on staff for eating and had physician orders for adaptive feeding equipment, was not provided the opportunity to use a weighted spoon and plate guard for self-feeding during a meal. Instead, a Restorative Nursing Assistant used the specialized utensils to feed the resident directly, rather than allowing the resident to attempt self-feeding as ordered. The resident's care plan and physician orders specified the use of these assistive devices to promote independence in eating, and the occupational therapist confirmed that these devices were intended to support the resident's self-feeding abilities. Interviews with facility staff, including the MDS nurse, occupational therapist, and Director of Nursing, verified that the adaptive equipment was present but was not used by the resident as intended. The occupational therapist was unaware that the resident was being fed by staff instead of using the assistive devices, and the Director of Nursing confirmed that the devices were meant for resident use, not staff. Facility policy also indicated that assistive devices are to be provided and supervised for resident use to support independence.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to implement the facility's infection prevention and control policy for one resident who was on enhanced barrier precautions (EBP) due to a wound requiring daily care. During wound care administration, a registered nurse and a certified nursing assistant did not don the required personal protective equipment (PPE), including an isolation gown, gloves, and mask, as mandated by the facility's EBP policy. This was directly observed by another registered nurse, who confirmed that the staff did not follow the established protocol for PPE use during high-contact care activities such as wound care. The resident involved had a history of hypertension, pain, and epilepsy, and required varying levels of assistance with daily activities, including being dependent for toileting hygiene, showering, and dressing. The resident had a treatment order for a right lateral heel wound, which required cleaning, application of ointment, and dressing changes. Both the Director of Nursing and the observing registered nurse acknowledged that EBP should have been implemented during direct care to protect the resident from infection, as outlined in the facility's revised policy.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who had been admitted with diagnoses including cerebral infarction, anxiety disorder, and chronic pain syndrome, was found to have their call light lying on the floor beneath the bed, out of reach. The resident's Minimum Data Set indicated intact cognitive skills but significant physical impairments, including upper and lower extremity impairment on one side and dependence on staff for most activities of daily living, including mobility and hygiene. During observation, the resident was lying in bed and unable to access the call light. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed that facility policy requires call lights to be within reach of residents to maintain safety. The resident's care plan also specified that the call light should be kept within easy reach and answered promptly. Review of the facility's policy and procedure further supported this requirement, stating that the call device must be placed within the resident's reach before staff leave the room. Despite these policies and care plan interventions, the call light was not accessible to the resident at the time of observation.
Failure to Prevent Elopement and Timely Response for At-Risk Resident
Penalty
Summary
A resident with a history of psychoactive substance abuse, alcohol-induced disorder, generalized muscle weakness, and unsteadiness on feet was admitted to the facility and assessed as being at risk for elopement. Despite this assessment, the facility failed to develop a care plan or implement interventions to address the resident's elopement risk. The resident had a physician's order allowing out on pass (OOP) privileges, but the order was non-specific, lacking details about duration, accompaniment, or supervision requirements. The resident left the facility independently for an OOP and did not return at the expected time. Facility staff did not initiate a search for the resident when he failed to return as scheduled, nor did they notify the DON, administrator, or local authorities in a timely manner. Documentation shows that the resident's absence was noted, and attempts were made to contact him by phone, but no further action was taken to locate him or escalate the situation according to facility policy. The lack of a clear care plan and failure to follow established elopement risk procedures contributed to the delay in recognizing and responding to the resident's absence. Interviews with staff and review of facility policies revealed that staff were unclear about the procedures to follow when a resident did not return from OOP. The facility's policies required timely searches and notifications, but these were not carried out. The resident remained missing for an extended period before the incident was reported to the appropriate authorities, including the police and the Department of Public Health. The failure to implement and follow elopement risk protocols resulted in an Immediate Jeopardy situation.
Removal Plan
- All residents with out on pass order were reviewed and updated including the duration, purpose, and companion. If the resident will not return after specified duration, facility will call resident/family/companion for update on whereabouts and the time of return. If resident requests to go out on pass independently, resident must meet all of the following criteria to be considered eligible and Interdisciplinary Team will review request to go out unaccompanied and document in Interdisciplinary notes: Cognitive Competency (Recent BIMS), Behavioral Stability (No recent history of elopement), Medical Stability (Medically cleared by Attending Physician), Functional Mobility.
- MDS Coordinator and Registered Nurse Supervisor re-assessed all residents with out on pass order and baseline care plan was updated. Elopement Risk Assessment was done for all residents. Residents were identified as low risk or high risk for elopement.
- Elopement Risk Policy and Procedures was revised and updated. The licensed personnel were in-serviced and educated regarding timely assessment and identification of residents with high risk of elopement. Any episode of elopement reported and communicated to the Director of Nursing and Administrator so the facility leadership will be able to inform residents family, physician, regulatory Police Department, Ombudsman, California Department of Public Health and other regulatory agencies.
- Director of Staff Development/Director of Nursing in-serviced the licensed personnel regarding Policy and Procedure for elopement to emphasize reporting to local police, administrator, and residents' representative within 2 hours and to California Department of Public Health within 24 hours when resident elopement.
- All residents with out on pass order were reviewed and updated including the duration, purpose, companion, and return time. A log was available to both nursing stations, regarding the time out and estimated time to return to the facility.
- Residents on high risk for elopement are potentially affected by the deficient practice. Residents identified as high risk were re-assessed, care plan was developed and implemented, including monitoring every two hours. Log was available in the nursing station.
- An in-service was provided to Licensed Nurses and direct care givers by the Director of Staff Development and Social Service Director pertaining to: How to alert staff about resident elopement or missing, How to locate or search the resident, Reporting to governing agencies within 2 hours and CDPH within 24 hours.
- The Director of Nursing/Designee and Director of Staff Development conducted in-service to Licensed Nurses and Certified Nursing Assistants pertaining to the following: Revised Policy and Procedure for Out on Pass, Physician order for out on pass, Duration and companion, Protocol if the resident did not return after specific duration, Resident's decision against medical advice.
- Policy and Procedure for Elopement.
- During daily angel rounds the Department Managers will check the out on pass log and discuss in the daily stand-up meeting.
- The Director of Nursing Services/Registered Nurse Supervisor is responsible for monitoring the residents on a daily basis to ensure that the deficient practice will not be impacted. Results of the findings will be submitted and discussed to QAPI Committee during the monthly/quarterly QAPI meeting of its effectiveness.
Failure to Provide Behavioral Health Services and Care Planning for Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a primary diagnosis of alcohol use disorder and psychoactive substance abuse. Upon admission, the resident's diagnoses included psychoactive substance abuse, unspecified alcohol-induced disorder, generalized muscle weakness, and unsteadiness on feet. Despite these diagnoses, there was no documented evidence that the facility developed or implemented a person-centered care plan addressing the resident's behavioral health needs related to substance use. Interviews and record reviews revealed that the resident was allowed to leave the facility on pass without specific orders regarding supervision or duration, and there was no indication that behavioral health interventions or referrals to a psychologist were made. The resident's clinical records, both paper and electronic, lacked documentation of any care plan or interventions targeting the resident's alcohol use or psychoactive substance abuse. Staff interviews confirmed that no such care plan was developed or discussed in the interdisciplinary care team meetings. Facility policies required that residents with substance use disorders receive individualized care plans and behavioral health services, including monitoring for substance use and supporting efforts to prevent further use. However, these policies were not followed in this case, as evidenced by the absence of a care plan, lack of behavioral health service referrals, and insufficient documentation of interventions to address the resident's substance use and associated risks.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident scratched another resident's face. The incident occurred when a resident with severe cognitive impairment, who required substantial assistance with daily activities and was known to exhibit verbal aggression, was being followed by a CNA as the resident wandered the hallways in a wheelchair. Despite being followed, the resident was able to abruptly get up from the wheelchair, enter another resident's room, and scratch the face of a resident who was lying in bed. The CNA reported turning his head away momentarily, during which time the incident occurred, and was unable to prevent the altercation. The resident who was scratched had a history of intact cognitive skills but required assistance with several activities of daily living. The injury was documented as a scratch on the nose, and treatment was ordered by the resident's physician. Interviews with staff indicated that the resident who committed the act was new to the facility and had been exhibiting aggressive behaviors that required close supervision. Staff acknowledged that the incident could have been prevented if the resident had been more closely monitored and redirected when attempting to enter another resident's room. Facility policy and procedures reviewed by surveyors indicated that residents have the right to be free from abuse and that staff are required to monitor individuals with dementia. The failure to adequately supervise and redirect the resident with aggressive behaviors resulted in a physical altercation and injury to another resident, constituting a deficiency in protecting residents from abuse.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precaution (EBP) policy, which is designed to prevent the spread of multi-drug resistant organisms (MDRO) by using targeted gown and glove use during high-contact resident care activities. Certified Nurse Assistant 1 (CNA 1) did not wear an isolation gown while changing the diaper of Resident 1, who was on EBP. Resident 1 had severe cognitive impairment and was dependent on staff for daily activities, including toileting and personal hygiene. The failure to wear an isolation gown during this high-contact activity was confirmed by CNA 1, who acknowledged the need for such protective measures to prevent infections. Additionally, the facility did not ensure the availability of isolation gowns in three of the five sampled rooms (Rooms A, B, and C) that required EBPs. Observations and interviews confirmed the absence of isolation gowns in these rooms, which were necessary for staff to use when providing care to residents to prevent cross-contamination. The Infection Prevention Nurse (IPN) and Licensed Vocational Nurse 1 (LVN 1) confirmed the deficiency, emphasizing the importance of having easy access to personal protective equipment (PPE) in EBP rooms to prevent the spread of infections among residents, staff, and visitors.
Failure to Document Resident-Initiated Discharge
Penalty
Summary
Facility 1 failed to maintain complete and accurate medical records for a resident who initiated a discharge to another facility. The resident, who had been admitted with multiple medical conditions including atrial fibrillation, paranoid schizophrenia, and various fractures, was evacuated to Facility 2 due to a fire. The resident expressed a desire to be relocated closer to friends and outside doctors, leading to a discharge to Facility 3. However, the facility did not document the resident's discharge coordination or the resident's wishes and preferences in the medical records. Interviews with the facility's staff revealed that there was a lack of documentation regarding the resident's discharge process. The Social Services Designee (SSD 1) did not document conversations with the resident about the discharge, and the Admissions Coordinator (AC) failed to record the resident's request to be transferred to another facility. Additionally, the facility's policy for resident-initiated discharges, which required documentation of the resident's intent to leave and discharge planning, was not followed. The facility's Administrator acknowledged the failure to document the discharge process, which was necessary to avoid confusion and ensure all healthcare team members were aware of the resident's preferences and the discharge details. The lack of documentation could potentially confuse the healthcare team and negatively impact service delivery, as the facility could not provide evidence of the discharge process or the resident's preferences.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the local police department, state survey agency, and ombudsman. The incident involved a resident with functional quadriplegia who reported an alleged physical abuse incident involving aggressive handling by staff, which resulted in pain in the resident's left hand. The resident, who had intact cognition, was dependent on staff for various activities and had a physician's order for an X-ray due to the complaint of pain. However, the resident refused the X-ray, opting to consult with family and a primary physician instead. The Social Services Worker received the report of the alleged abuse from the charge nurse eight hours after the incident was initially reported by the resident. The Director of Nursing acknowledged that the charge nurse, who had been trained in abuse reporting, should have notified the Administrator immediately within the two-hour mandate. The Administrator, who is the facility's Abuse Coordinator, confirmed that the charge nurse failed to follow the facility's policy, which requires immediate reporting of abuse allegations. The facility's policy mandates that all alleged violations involving abuse must be reported immediately to the administrator and relevant authorities, but this was not adhered to in this case.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 6,632 citations issued within 25 miles in the last 12 months — including the 26 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 Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pasadena Nursing Center | 0.1 mi | ★★★★★ | 29 | 0 |
| Saint Vincent Healthcare | 0.2 mi | ★★★★★ | 15 | 0 |
| Foothill Heights Care Center | 0.2 mi | ★★★★★ | 24 | 0 |
| Brighton Care Center | 0.2 mi | ★★★★★ | 24 | 0 |
| Pasadena Grove Health Center | 0.2 mi | ★★★★★ | 26 | 0 |
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