Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chestnut Ridge Post Acute Llc during CMS and state inspections, most recent first.
Failure to Supervise Mobility and Smoking Safety: A resident with impaired mobility and confusion was observed walking by pushing a wheelchair like a FWW despite records showing the resident needed assistance and supervision for transfers and ambulation. Several residents who smoked had incomplete smoking safety documentation or lacked required care planning, and staff observed unsafe smoking-related behavior including sharing cigarettes, carrying lighters, and possession of marijuana in a resident’s belongings. Interviews with CNA, PT, DON, and other staff confirmed gaps in supervision, smoking monitoring, and documentation.
A resident with Parkinson’s disease, cognitive impairment, unsteady gait, and bowel and urinary incontinence experienced unwitnessed falls with injury after the facility failed to keep the call light within reach, ensure the bed alarm was functioning, complete fall risk assessments, and document a thorough post-fall investigation. The resident sustained a forehead laceration requiring sutures and a scalp hematoma, reported pain after the falls, and the DON acknowledged the facility lacked documentation of a resident-specific investigation and interventions tied to the resident’s incontinence and mobility needs.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with type 1 DM experienced a documented hypoglycemic episode after receiving ordered insulin, with blood glucose dropping to 60 mg/dL and then rising to 72 mg/dL after treatment with juice and food. The LVN administered insulin, treated the low blood sugar, and monitored the resident, but did not notify the MD as required by the resident’s orders and facility policies, and there was no documentation of MD notification in the EHR. This failure to follow provider notification orders and hypoglycemia management policy led to the cited deficiency.
A resident with shingles and blisters on the lower back and bilateral buttocks had a physician’s order for daily wound care, but nursing staff failed to assess, monitor, and document the skin condition on admission and weekly thereafter as required by facility policy and practice. The TXN and IP confirmed there was no documentation of ongoing assessment of the blisters, and a covering LVN reported she was not informed she needed to complete weekly skin checks. The DON verified that the admission skin assessment and subsequent weekly skin checks were not completed or documented, despite policies requiring documentation of wound assessments and admission skin assessments.
A resident with a full code status did not receive immediate or effective BLS/CPR when found unresponsive, as staff delayed initiating CPR while searching for code status, failed to use a backboard or Ambu-bag, and performed inconsistent chest compressions. Some staff lacked current BLS/CPR certification, and the emergency cart was not properly stocked, resulting in inadequate life-saving measures.
The facility did not ensure that POLST and advance directive documents were consistently filed and readily accessible in the current medical charts for multiple residents, including those with impaired cognition and serious health conditions. During a medical emergency, staff were unable to locate a resident's POLST, resulting in default initiation of CPR. Staff interviews and record reviews revealed that required documents were often missing, stored in old charts, or not obtained, contrary to facility policy.
Staff failed to immediately initiate CPR and call a code blue when a resident was found unresponsive. Instead, staff delayed action by searching for the resident's code status and did not use the backboard or Ambu-bag during resuscitation. CPR was performed incorrectly, with inadequate compressions and no rescue breaths, and EMS had to move the resident to the floor to continue efforts. These failures resulted in the resident's death and placed all full code residents at risk.
A resident with severe respiratory conditions did not receive prescribed respiratory medications as ordered, with numerous missed and undocumented doses. Staff failed to monitor or assess the resident for respiratory distress after new symptoms and abnormal lab and x-ray results were identified. Critical results were not effectively communicated to the physician, and the care plan was not updated to address the resident's worsening condition. The resident was later found unresponsive and died despite resuscitation efforts.
Licensed nurses did not administer or document multiple scheduled doses of prescribed respiratory medications for a resident with COPD, emphysema, and respiratory failure. The resident, who was oxygen-dependent and required total staff assistance, missed numerous doses of Acetylcysteine, Budesonide, and Ipratropium-Albuterol over several months, despite physician orders and care plan interventions requiring these treatments. The DON and physician confirmed the medications were not given as ordered, in violation of facility policy.
A resident with multiple respiratory conditions and impaired cognition had abnormal lab and chest x-ray results indicating a possible infection. Nursing staff failed to verify that these results were received by the physician or nurse practitioner, and there was no documentation of provider notification or follow-up. As a result, the resident did not receive timely medical intervention for the abnormal findings, and required notification procedures were not followed.
A resident with severe respiratory illnesses, dependent on staff for all care, did not have timely documentation of medication administration by nursing staff. Instead, LPNs entered medication records days or weeks after administration, often only after being alerted by medical records audits. Staff could not recall specific details about medication administration, and documentation was not completed as required by facility policy.
Staff Competency Deficiencies in CPR and Emergency Equipment Use: CNA 1 and CNA 2 gave incorrect responses about when to check for pulse and breathing and did not know the correct CPR compression rate. RN 1 and RN 2 could not identify key crash cart supplies, and RN 1 could not demonstrate how to set up or check the suction machine or oxygen tank. The DSD also demonstrated incorrect compression counting, and the facility had no documented evidence that staff competencies were evaluated during mock Code Blue drills.
An agitated resident with a history of behavioral disturbances was left unattended in a shared room after a CNA unsuccessfully attempted to intervene, resulting in the resident striking another bedbound resident multiple times with metal wheelchair footrests and causing severe facial injuries. The injured resident required emergency medical care, while another roommate witnessed the attack and expressed fear. Staff were aware of the aggressive resident's history and care plan requirements but failed to implement appropriate interventions or utilize available methods to ensure the safety of all residents present.
A resident with anxiety disorder and moderate cognitive impairment was not assessed or provided with psychosocial support after witnessing and being threatened during a violent incident involving another resident with severe behavioral disturbances. Despite the resident expressing fear and emotional distress, staff did not follow up or notify social services, contrary to facility policy.
A resident with right elbow and right hand contractures had physician-ordered PROM and splinting delayed by 22 days. The order summary and RNA documentation showed the restorative services should have started earlier, but the RNA, OTD, and DON confirmed they did not begin until later, and the RNA could not recall why the services were not initiated. The DON stated the nurse receiving the order should have notified the RNA.
Unsafe Use of Extension Cord and Power Strip in Resident Room: A resident with intact cognition and dependence on supplemental O2 had an extension cord and power strip placed directly on the bed, with multiple devices plugged in and the strip positioned beside the O2 machine and nebulizer. An RN and the Maintenance Supervisor both stated the setup was dangerous and a fire hazard, and the facility policy required electrical devices and extension cords to be used safely and secured to prevent injury.
Expired and unlabeled food items were found in dry storage and the freezer, including spices, mixes, frozen vegetables, and meat stored without required dates or in opened packaging. A kitchen staff member was also observed handling dirty dishes and then clean dishes with the same gloves without hand hygiene, contrary to facility policy for food storage and employee sanitation.
A resident with severely impaired cognition and no capacity to make decisions had an order for Ativan for anxiety, but the informed consent for the psychotropic medication was missing the LN’s signature and date. The MRA, RN supervisor, and DON confirmed the consent was incomplete and stated the signature and date were needed to verify the POA received and understood the consent information.
A resident with Parkinson's disease, HTN, and moderately impaired cognition had an incomplete ADA form on admission. The form lacked key resident and facility identifiers, and the RP did not initial statements confirming education on the right to accept or refuse tx, the right to formulate ADs, or whether an AD would be executed or declined. The SSD could not confirm that staff had explained these rights during the IDT meeting.
A resident with HTN heart disease, anemia, COPD, impaired cognition, and a need for altered food texture had dental issues and requested dentures to improve mastication, but the facility did not develop a baseline comprehensive person-centered care plan for the resident’s teeth, dentures, or chewing concerns. Dental notes documented missing teeth and recommended x-rays, oral prophylaxis, a filling, dentures, and possible extractions, while staff and the DON confirmed no care plan was found for these needs.
Failure to follow up on medically-related social services for a resident with missing teeth and a request for dentures. The resident had impaired cognition, needed help with oral hygiene, and required a modified diet. Dental notes recommended x-rays, oral prophylaxis, treatment for tooth decay, and fabrication of upper and lower dentures, but the SSD had no documented follow-up, no dental care plan, and no evidence of communication with the resident about the dentist’s recommendations. The resident was observed with several missing teeth and stated she needed dentures to chew food and felt forgotten.
Failure to provide needed dental services for a resident with missing teeth, dental cavities, and difficulty chewing. The resident had impaired cognition, needed supervision with oral hygiene, and required texture-modified food or liquids. Dental notes documented a request for dentures and later recommended x-rays, oral prophylaxis, a filling, dentures, and extraction of root fragments, but social work notes showed no documented follow-up on the denture issue. The resident said she had been asking for dentures for months and felt forgotten, while an LVN said the resident never wore dentures and the DON stated the IDT should have communicated better.
Infection control measures were not implemented for two residents when respiratory treatment equipment was found without the resident’s name or date and a PICC dressing was observed without a date. Staff stated the nebulizer equipment should be labeled and stored properly and that the PICC dressing should be dated to track when it was last changed. Facility policies required labeled respiratory equipment in a plastic bag and dated IV dressings to help maintain aseptic care and monitor dressing-change intervals.
Room Not Kept Clean and Free of Stains and Dust: A resident with dementia and DM2 was observed in a room with dry brown stains on the wall and a dusty exhaust vent. The resident said the stains were already there when she moved in and that she had not seen the vent cleaned, stating the room was not clean and she did not feel comfortable. Staff confirmed housekeeping had not cleaned the wall or vent cover, and the HKS stated rooms should be cleaned daily and checked for cleanliness.
A resident did not receive the necessary behavioral health care and services as required. The facility did not provide appropriate behavioral health interventions and supports, as observed and documented by surveyors.
A resident with severe cognitive impairment and a history of wandering was identified as being at risk for elopement, but no care plan was developed to address these behaviors. Staff and DON confirmed the absence of a care plan, despite facility policy requiring interventions and measurable objectives for such risks.
A resident with a history of schizoaffective and psychotic disorders exhibited aggressive behaviors, including choking a CNA and later threatening staff with a knife. After readmission from psychiatric care, the facility did not develop or communicate an individualized behavioral care plan or interventions to staff, despite repeated incidents of aggression and facility policy requirements for comprehensive, person-centered care planning.
Two incidents of abuse occurred when a resident verbally and physically assaulted another resident and later choked a CNA. Both events were witnessed by staff and a family member, but were not reported to the abuse coordinator, ombudsman, police, or state health authorities as required by policy. The affected resident experienced emotional distress, and the lack of timely reporting increased the risk of recurrence and harm.
A resident with dementia and high elopement risk wandered away from an LTC facility due to insufficient staff intervention and training. Despite the resident's care plan requiring frequent monitoring and behavioral intervention, staff failed to act when the resident became agitated and refused to re-enter the facility. The resident was missing for over two hours before being found by law enforcement and placed on a 72-hour hold.
A resident with dementia and high elopement risk managed to leave the facility unsupervised due to inadequate monitoring. The receptionist left his post without coverage, allowing the resident to exit without triggering the wander guard alarm. Facility staff interviews highlighted a failure to adhere to supervision protocols, leading to the resident's elopement and police involvement.
A resident with moderate cognitive impairment requested access to her medical records, but the facility failed to provide the necessary release form, violating her rights. The Administrator instructed the Medical Records Staff to provide the form but did not ensure it was done. The staff claimed the resident later declined the records, which the resident denied, and this was not documented.
The facility failed to ensure the accessibility of the survey binder containing past survey results for residents, as required by policy. During a resident council meeting, residents expressed their unawareness of the survey report's location and the facility's corrective actions. The DON confirmed the binder's importance but could not locate it, as it was taken by MR staff and not returned.
The facility failed to complete quarterly MDS assessments for four residents within the required timeframe, with delays ranging from 27 to 33 days. The MDS Nurse cited a backlog of assessments as the reason for the delays. The DON acknowledged the issue, noting that late assessments could hinder timely updates to care plans. The facility's policy requires MDS completion within 14 days of the ARD, which was not followed.
A facility failed to develop comprehensive care plans for several residents, including one with dementia and others on psychoactive medications, leading to deficiencies in care. A resident with dementia lacked a care plan for their condition, while two residents on psychoactive medications did not have plans to guide safe medication use. Another resident's refusal to store their nasal cannula properly was not addressed in their care plan.
The facility failed to provide proper respiratory care for four residents, including not posting oxygen warning signs for two residents, administering oxygen without a physician's order for one resident, and improper storage and timely replacement of nebulizer equipment for two residents, leading to potential health risks.
The facility failed to maintain proper food storage and sanitation practices, risking foodborne illnesses for residents. Open food items lacked labels and dates, and expired items were found in the kitchen. The Sanitizer Bucket Log, Ice Machine Cleaning Log, and Cleaning and Maintenance Schedule Log had missing entries, indicating inconsistent sanitation practices. The Dietary Service Supervisor admitted to not ensuring logs were completed accurately, contrary to facility policies.
The facility failed to implement its infection control program, leading to deficiencies involving six residents. Issues included unlabeled and improperly stored medical equipment, failure to change feeding syringes, lack of disinfection of reusable equipment, and inadequate hand hygiene practices. These oversights were confirmed through observations and staff interviews, highlighting potential risks of infection spread.
A resident with dementia and psychotic disorder was prescribed Quetiapine and Zolpidem without obtaining informed consent, violating their rights. The facility's policy requires a physician to explain medication effects and alternatives, but documentation was incomplete, lacking the physician's signature.
A resident with communication challenges was not provided with a communication board, despite recommendations from a Speech-Language Pathologist. Staff struggled to understand the resident's needs, leading to frustration and unmet needs. The Director of Nurses acknowledged the availability of communication boards, but staff were unaware of them.
A resident with hemiplegia and dysphagia was not provided necessary assistance during mealtimes, leading to difficulty eating independently. Despite documented needs for supervision and assistance, the resident was left alone, struggling to cut and consume food. A CNA and the DON confirmed the resident required help due to right-side weakness, highlighting a failure to adhere to the facility's ADL support policy.
A resident with severe cognitive impairment and total dependence on staff had their low air loss mattress set incorrectly for a much higher weight than their actual 204 pounds. This error, confirmed by a Treatment Nurse, increased the risk of further skin breakdown and hindered wound healing, as the mattress was too hard. The manufacturer's manual specifies adjusting air pressure based on the patient's weight and comfort, which was not followed.
A facility failed to provide appropriate rehabilitation services and devices for a resident with limited mobility and contractures. The resident was observed with rolled towels between their contracted arms instead of the recommended splints. The facility's physical therapist and rehabilitation director stated that splints should have been used, as rolled towels are not effective. The resident had not been referred for reassessment since 2021, despite the need for appropriate devices to prevent further decline.
The facility failed to maintain a safe environment for two residents. A resident's bed alarm was non-functional, increasing fall risk, while another resident on oxygen therapy had tobacco in their room, posing a fire hazard. Staff acknowledged these oversights, which violated facility policies.
A resident with cognitive impairment was administered medication without proper identity verification. The LVN failed to use multiple identifiers as required by the facility's policy, relying only on the resident's last name. The resident lacked an ID band, and there was no profile picture in the EHR, increasing the risk of medication errors.
Two residents in a LTC facility were found to be on unnecessary psychotropic medications due to inadequate monitoring and documentation. One resident was prescribed Risperidone and Trazodone without specific behavioral indications, and no gradual dose reduction was attempted. Another resident was given Lorazepam without a physician's order after the original order expired. The facility failed to follow its policies on psychoactive drug monitoring and medication administration.
The facility failed to ensure proper storage and labeling of medications. A non-functioning thermometer in the medication room led to unrecorded temperatures, risking medication potency. A resident's medications were improperly labeled with only a room number, not the resident's name, risking medication errors. Additionally, opened multi-dose bottles lacked open dates, crucial for determining expiration. Staff acknowledged these lapses, which violated the facility's policy on medication storage and labeling.
A resident with dysphagia was not provided with the prescribed mechanical soft diet, receiving regular texture food instead, due to an error in the facility's dietary order system. This oversight, lasting from July to October, placed the resident at risk for aspiration and choking. The resident's care plan and physician's orders were not followed, as observed during a dining session where the resident was eating unassisted.
A resident was not screened for the pneumococcal vaccine within the required timeframe upon admission, as per facility policy. The resident, with moderately impaired cognition and requiring assistance with daily activities, was not offered the vaccine until 22 days after admission due to the Infection Preventionist being occupied with other tasks. Both the IP and DON acknowledged the oversight.
Failure to Supervise Mobility and Smoking Safety
Penalty
Summary
The facility failed to provide a hazard-free environment and adequate supervision related to falls and smoking safety for five sampled residents. The report states that the facility did not follow its Falls and Fall Risk policy and its Smoking Policy for residents who were identified as smokers or at risk for unsafe mobility. The deficient practices were identified through record review, interviews, and observation, and included failures to supervise ambulation, complete required smoking safety assessments, monitor smoking-related behavior, and develop or update care plans and interdisciplinary interventions when resident conditions or behaviors changed. For the resident with mobility concerns, the record showed diagnoses including major depressive disorder with psychotic symptoms, unsteadiness, lack of coordination, and dementia, and the H&P stated the resident did not have the mental capacity to make medical decisions. The MDS and fall risk evaluations showed the resident needed assistance with transfers and walking, was chairbound, and had balance problems, while the IDT conference after a fall directed hands-on assistance with transfer and ambulation. PT notes instructed use of a FWW, and the PT progress report stated the resident would safely perform functional transfers with standby assistance for correct use of an assistive device. However, CNA interviews stated the resident usually walked around the facility pushing a wheelchair like a FWW, and the PTA stated the resident was very confused and impulsive and should be supervised while walking at all times. The DON reviewed the care plan and stated she would follow up regarding safe use of a wheelchair versus the FWW. For the smoking-related deficiencies, one resident with diagnoses including DM, COPD, and atherosclerotic heart disease had a Smoking and Safety form indicating tobacco use and compliance with designated smoking locations and times, but the record did not show a comprehensive smoking care plan. During observation and interview, the resident handed another resident two cigarettes and received a dollar bill in return, and the resident stated he kept a lighter in his possession and showed it to the surveyor. Another resident with COPD, lack of coordination, and nicotine dependence had a Chronic Smoker Care Plan, but the Smoking and Safety record did not include a care plan or measures to ensure safety. A third resident with COPD, unsteadiness, and generalized muscle weakness had a Smoking and Safety form indicating tobacco use and balance problems, but the record did not include a care plan or safety measures; during observation, the resident had two lighters and cigarettes in his possession. A fourth resident with DM, unsteadiness, and generalized muscle weakness had a Smoking Care Plan and Smoking and Safety form, but the assessment did not identify what the resident’s “other” smoking material was. The resident stated another resident tried to hand him a joint, and staff later reported marijuana was found in the resident’s belongings after discharge and that the resident later asked specifically for his marijuana. Staff also stated there was no documented evidence in the chart regarding the marijuana finding and that the facility’s process was to conduct an IDT and implement a care plan, but that was not done.
Incomplete fall assessment and supervision for a resident with incontinence and mobility impairment
Penalty
Summary
The facility failed to maintain a hazard-free environment and provide adequate supervision for a resident with Parkinson’s disease, dyskinesia, stage 4 sacral pressure ulcer, unsteadiness on feet, and bowel and urinary incontinence. The resident’s admission and hospital records showed a recent hospitalization for sacral wound infection and urinary retention with a Foley catheter, and the resident’s MDS reflected moderate cognitive impairment, dependence for transfers and toileting, and always being incontinent of bowel and urine without a toileting program. The resident’s fall risk evaluation completed after admission was incomplete, did not include a fall risk score or interventions, and was not signed or dated by the staff member who initiated it. The resident’s care plan identified interventions to keep the call light within reach, answer it promptly, keep frequently used items within reach, and keep the bed in a low position. However, the record and staff interviews showed the resident’s call light was not always within reach, the bed was not in a low position, and the bed alarm was not functioning as expected at the time of the first fall. On 11/11/2025, the resident was found on the floor with a right forehead laceration and bleeding after an unwitnessed fall while attempting to self-toilet. The resident was transferred to the hospital, where CT imaging showed a right anterior scalp hematoma and the ED physician placed four sutures to close a stellate laceration on the right forehead. The resident reported pain after the fall, and staff documentation did not include a completed rehab post-fall assessment in the medical chart. After the first fall, the facility’s documentation remained incomplete. The post-fall and change-in-condition records did not consistently include the exact circumstances of the fall, and the interdisciplinary fall follow-up did not document all interventions to prevent recurrence. The resident later had another fall, and the change-in-condition record again lacked key details such as the exact time, location, how the resident was found, who witnessed the event, what occurred before the fall, and the immediate interventions provided. The fall risk evaluation was not completed after this second fall, and the fall management follow-up was incomplete and lacked staff signature and date. Interviews with the DON, MDS nurse, rehab staff, CNA, LVN, and the resident confirmed that the facility did not complete a thorough internal investigation of the falls, did not document a resident-specific bowel/bladder program assessment, did not document that the bed alarm was monitored as functioning, and did not document that the resident’s call light was always within reach.
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Notify Physician After Resident Hypoglycemic Episode
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a diabetic resident’s hypoglycemic episode despite explicit orders and facility policies requiring such notification. The resident was admitted with diagnoses including type 1 diabetes, duodenal ulcer, and muscle weakness, and was documented as cognitively intact, requiring varying levels of assistance with activities of daily living. Active physician orders and the resident’s diabetes care plan both directed staff to call the provider immediately if the resident’s blood glucose was less than 70 mg/dL and to call as soon as possible when blood glucose values were regularly 70–100 mg/dL for possible regimen adjustment. On the day of the incident, progress notes documented that the resident’s pre-lunch blood glucose was 371 mg/dL and that insulin was administered as ordered. After lunch, the resident’s blood glucose was rechecked and found to be 60 mg/dL. In response, the nurse provided juice and a parfait, and a subsequent blood glucose check showed an increase to 72 mg/dL. The resident was monitored and noted to have no signs of distress. However, there was no documentation in the progress notes that the physician was notified of the hypoglycemic episode, despite the blood glucose level being below 70 mg/dL. During interviews, the LVN who provided care stated that she administered insulin per order, treated the low blood sugar with juice and a parfait, rechecked the blood sugar, and continued to monitor the resident, but forgot to notify the physician of the change in condition. Review of the electronic health record by the DON, QA nurse, and medical records director confirmed there was no documentation that the physician was notified of the hypoglycemic event. Facility policies on Management of Hypoglycemia and Change in a Resident’s Condition or Status required immediate provider notification for blood glucose less than 70 mg/dL and prompt physician notification of changes in a resident’s medical condition, particularly when there were specific instructions to notify the physician of such changes. The failure to notify the physician after the documented hypoglycemic episode constituted the cited deficiency.
Failure to Assess and Document Shingles-Related Skin Condition
Penalty
Summary
The deficiency involves the facility’s failure to assess, monitor, and document a resident’s shingles-related blisters in accordance with its wound care and admission assessment policies and usual practice. The resident was originally admitted with diagnoses including anxiety disorder and hypertension and had moderately impaired cognitive skills, requiring varying levels of assistance with ADLs. A physician’s order directed that the shingles rash on the resident’s bilateral buttocks be cleansed with normal saline, patted dry, and covered with foam dressing daily for 14 days. On admission, a CNA observed red, painful dots on the resident’s lower back area, and the Treatment Nurse (TXN) later confirmed seeing red blisters due to shingles on the lower back when she assessed the resident. The TXN stated that the RN supervisor was responsible for documenting the resident’s skin condition related to the blisters but did not do so, and there was no documentation in the clinical record that the blisters were assessed, documented, and monitored for two weeks starting from the initial assessment date. The TXN also reported that she had been off work for the past two weeks and that the covering nurses did not complete the Weekly Skin Check for the resident during that period. The Infection Preventionist (IP) confirmed awareness that the resident had shingles and blisters upon admission and verified that there was no documentation indicating that the skin condition due to shingles had been assessed, documented, and monitored since admission. A covering LVN reported providing wound care for the resident for the prior two weeks but stated she did not know, and it was not endorsed to her, that she should assess and complete the Weekly Skin Check for the resident. The DON confirmed that the RN supervisor did not assess and document the resident’s shingles blisters on the Skin Check upon admission and that nurses did not assess and document the Weekly Skin Check on the specified subsequent weeks. Review of the facility’s wound care policy showed that nurses are required to record all assessment data obtained when inspecting wounds and any change in the resident’s condition in the medical record, and the admission assessment policy requires nurses to conduct and document physical and skin assessments at admission. The DON stated that, although the wound care policy did not specify follow-up frequency, the facility’s practice was to reassess and document shingles blisters weekly to monitor healing.
Failure to Provide Timely and Effective BLS/CPR to Full Code Resident
Penalty
Summary
Facility staff failed to provide proper and effective Basic Life Support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who was identified as full code when found unresponsive, pulseless, and not breathing. Multiple staff members, including CNAs, RNs, and LVNs, did not immediately call a code blue or initiate CPR upon discovering the resident's condition. Instead, staff delayed action while attempting to verify the resident's code status, and there was confusion and lack of clarity among staff regarding the resident's code status and the location of this information in the medical record. Chest compressions were not started until approximately 12 minutes after the resident was found unresponsive. When CPR was eventually initiated, it was performed on the resident's bed without first placing the resident on a firm, flat surface or using a backboard, which was available in the facility. Staff did not consistently perform continuous and uninterrupted CPR, and there were inconsistencies in the rate and quality of chest compressions. Additionally, staff failed to use the Ambu-bag for rescue breathing, instead placing a non-rebreather mask on the resident, which is not appropriate during CPR. EMS personnel arriving at the scene observed these deficiencies and had to move the resident to the floor to continue CPR. Interviews and record reviews revealed that some staff members lacked current BLS/CPR certification, and there were discrepancies in staff knowledge regarding proper CPR procedures, including compression rates and the use of equipment. Documentation and staff statements indicated that the emergency cart was not properly checked or restocked, resulting in missing essential equipment such as the Ambu-bag. These failures resulted in the resident not receiving timely and effective life-saving measures as required by their full code status.
Removal Plan
- Quality Assurance Nurse (QA) and the RN on duty review the current residents' care profile in the facility's electronic health record (EHR) system, Code Status.
- QA and the RN verify the residents' Code Status via POLST forms and/or physician's orders for Code Status and input the data accordingly in the residents' care profile under Code Status.
- A copy of the list of Full Code residents is made readily available to staff at the nurse's station for reference and is updated by the Social Services Director (SW) 1/designee on every admission/readmission and as needed.
- DON/Designee provides in-service education to nursing staff regarding the availability of the list of residents who are Full Code.
- DON checks the Emergency Cart (EC) and ensures that CPR backboard is available.
- RN and/or Designated Licensed Nurse conduct inventory on the EC utilizing the Emergency Cart Checklist and ensure that CPR backboard is readily available. This is validated by the DON and/or Designee.
- RN and/or Designated Licensed Nurse conduct inventory of the EC utilizing the Emergency Cart Checklist every shift to ensure that all necessary items listed are readily available, including, but not limited to, the CPR backboard.
- DON initiates in-service to RNs, LVNs, and CNAs regarding ensuring a CPR backboard is readily available and used accordingly.
- DON initiates in-service to RNs, LVNs, and CNAs regarding providing rescue breathing, not placement of a non-rebreather mask.
- DON provides continued in-services for all of the facility's RNs, LVNs, and CNAs.
- DON initiates in-service to RNs, LVNs, and CNAs regarding effective and appropriate procedure for CPR, including performing adequate and appropriate chest compressions and rescue breathing, effective and continuous CPR, and ensuring a CPR backboard is readily available and used accordingly.
- Director of Staff Development (DSD) reviews employee files for all current Licensed Nurses and CNAs, specifically to validate that all CPR cards are up to date.
- Identified CNA attends the CPR certification training and is put on temporary suspension until CPR certification is received as part of Direct Care Staff competency.
- Identified LVN that does not have a current CPR/BLS certification is placed on suspension and is not permitted to return to work without an active certification for CPR/BLS.
- Clinical Nurse Consultant provides 1:1 in-service education to the DSD regarding the importance and significance of monitoring and validating direct staff's BLS/CPR competencies and filing of CPR cards.
- DON/Designee provides in-service to CNA 1, CNA 2, LVN 2, and RN 1 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
- DON/Designee provides in-service to LVN 2 upon returning to work. LVN 2 is not on the schedule until education/reeducation is provided regarding the facility's policy and procedure titled, Emergency Procedures - Cardiopulmonary Resuscitation.
- DON/Designee provides in-service to LVN 5 regarding the facility's policy and procedure titled Emergency Procedures - Cardiopulmonary Resuscitation with the emphasis on immediate code activation and calling for help, hard surface/backboard placement before compression, BVM rescue breathing with appropriate rate/volume, and high-quality compressions including the rate, depth, recoil and minimal interruptions.
- A Certified CPR instructor provides mandatory re-education and training for all Licensed Nurses and CNAs which is also attended by the DON and DSD with return demonstration conducted.
- A series of ongoing CPR Certification Training sessions is provided by a Certified CPR instructor until all current Licensed Nurses and CNAs have been provided re-education and training.
- A Code Blue drill is initiated and continues weekly, once per shift for 3 months and monthly thereafter for the purpose of Skills Check Validation through return demonstration of Licensed Nurses and CNAs response to Code Blue situations and providing effective BLS, including CPR.
- An RN is designated as the team leader for Code Blue emergencies.
- Additional CPR training is provided by a Certified CPR Instructor to provide mandatory re-education and training for all Licensed Nurses and CNAs with return demonstration.
- Any Licensed Nurses or CNAs are not permitted to work directly with patients if they do not complete the Certified CPR refresher course.
- Director of Staff Development (DSD)/Designee maintains a log for all Direct Care Staff of their active Certification for BLS/CPR.
- DSD/Designee notifies staff with BLS/CPR certification expiring within a month.
- DSD/Designee presents to the QAA Committee the monthly log for all Direct Care Staff Certification for monitoring and compliance on BLS/CPR certification.
- No Direct Care Staff are permitted to work directly with patients without an active BLS/CPR certification.
- QAA Committee reviews audit findings from the DSD/Designee on BLS/CPR Certification monitoring for further needed corrective actions.
Failure to Maintain Readily Accessible POLST and Advance Directives in Resident Charts
Penalty
Summary
The facility failed to ensure that Provider Orders for Life-Sustaining Treatment (POLST) and advance directives (AD) were consistently and readily retrievable in the current medical charts for 11 out of 100 sampled residents. This deficiency was identified through observation, interviews, and record reviews, which revealed that staff were unable to locate these critical documents during medical emergencies. In one instance, when a resident was found unresponsive and pulseless, nursing staff could not find the resident's POLST or code status in the current chart and, as a result, initiated CPR by default, treating the resident as full code. The Director of Nursing later found the resident's POLST in an old chart, confirming that the document was still valid at the time of the emergency but had not been placed in the current chart as required by facility policy. Further review of additional residents' records showed similar issues, with several POLST and AD documents missing from current medical charts. Interviews with staff, including nurses and the social worker, confirmed that these documents were either not obtained, not printed, or were kept in locations such as email inboxes or old charts rather than being filed in the residents' current medical records. The facility's policy and procedures, as well as the social worker's job description, require that POLST and AD documents be obtained within 48 to 72 hours of admission and be accessible in the medical record to all facility staff. However, staff interviews revealed a lack of consistent adherence to these procedures, with some staff unaware of whether residents had POLST forms or failing to ensure the documents were properly filed. The deficiency affected residents with a range of medical conditions, including chronic obstructive pulmonary disease, chronic kidney disease, dementia, quadriplegia, and other serious health issues. Many of these residents had impaired or severely impaired cognition and lacked the capacity to make decisions, making the presence and accessibility of POLST and AD documents especially critical. The failure to maintain these documents in the current medical charts was acknowledged by both the Director of Nursing and the social worker, who confirmed that the documents should be readily available in the chart and not stored elsewhere.
Failure to Provide Qualified Emergency Response and CPR
Penalty
Summary
Facility staff failed to provide care by qualified persons according to a resident's written plan of care, specifically in the response to a full code resident who was found unresponsive. Multiple staff members, including CNAs, RNs, and LVNs, did not immediately initiate a code blue or begin CPR when the resident was discovered unresponsive. Instead, staff delayed action by first attempting to verify the resident's code status and searching for the POLST form, rather than starting life-saving measures as required by facility policy and professional standards. Interviews and record reviews confirmed that staff were unclear about the correct sequence of actions and did not follow established protocols for emergency response. When CPR was eventually initiated, staff did not place the resident on a firm, flat surface or use the available backboard, as required to ensure effective chest compressions. Instead, CPR was performed on the bed, and the backboard was not utilized. Additionally, staff failed to provide rescue breaths using the Ambu-bag, despite its availability, and instead left the resident on a non-rebreather mask, which is not appropriate during CPR. EMS personnel arriving at the scene observed that CPR was being performed incorrectly, with inconsistent and inadequate chest compressions, and had to move the resident to the floor to continue resuscitation efforts. Documentation and interviews revealed further deficiencies in staff knowledge and execution of CPR, including incorrect compression rates, lack of rescue breaths, and failure to use proper equipment. The facility's own policies, as well as American Heart Association guidelines, were not followed. As a result, the resident was pronounced deceased after prolonged and inadequate resuscitation efforts. The failure to provide qualified and timely emergency care placed all full code residents at risk of not receiving proper life-saving measures during a code blue event.
Failure to Provide and Document Respiratory Care and Timely Physician Notification
Penalty
Summary
The facility failed to provide necessary respiratory care and interventions for a resident with multiple respiratory diagnoses, including COPD, emphysema, respiratory failure with hypoxia, and recurrent pneumonia. The resident was dependent on staff for all care and had significantly impaired cognition. Despite physician orders for scheduled respiratory medications—Acetylcysteine, Budenoside, and Ipratropium-Albuterol—there were numerous missed and undocumented administrations over several months, as evidenced by gaps in the Medication Administration Record (MAR). These medications were specifically ordered to manage the resident's COPD, chest congestion, and shortness of breath, but the resident did not consistently receive them as prescribed. In addition to missed medications, the facility did not adequately monitor or assess the resident for respiratory distress or changes in condition, even after new symptoms and abnormal findings were identified. When a nurse practitioner noted cough, congestion, abnormal lung sounds, and respiratory distress with low oxygen saturation, and when abnormal laboratory and chest x-ray results were received indicating possible infection, there was no documented assessment or monitoring of the resident's respiratory status. The care plan was not revised to address the new or worsening symptoms, and there was no evidence of nursing interventions being initiated in response to these changes. Furthermore, the facility failed to ensure timely and effective communication of critical lab and diagnostic results to the resident's physician. Although results were faxed and texted, there was no confirmation that the physician or nurse practitioner received or reviewed the information. Nurses did not follow up with phone calls or verify receipt, and there was no documentation of provider notification or discussion of the abnormal findings. This lack of communication delayed necessary medical evaluation and treatment. Ultimately, the resident was found unresponsive and pulseless, and despite CPR, was pronounced dead. The facility's policies required prompt assessment, monitoring, and provider notification for changes in condition, but these procedures were not followed.
Failure to Administer Prescribed Respiratory Medications
Penalty
Summary
Licensed nurses failed to administer prescribed respiratory medications to a resident with chronic obstructive pulmonary disease (COPD), emphysema, respiratory failure with hypoxia, recurrent pneumonia, and vascular dementia. The resident was oxygen-dependent and required staff assistance for all activities of daily living. The care plan specifically included interventions to administer medications as ordered for impaired gas exchange and ineffective airway clearance. A review of the Medication Administration Records (MAR) for three months revealed that multiple scheduled doses of three critical respiratory medications—Acetylcysteine Inhalation Solution, Budesonide Inhalation Suspension, and Ipratropium-Albuterol Inhalation Solution—were not documented as administered. Specifically, there were 25 undocumented doses of Acetylcysteine, 31 undocumented doses of Budesonide, and 60 undocumented doses of Ipratropium-Albuterol. Physician progress notes during this period consistently indicated the need to continue regular breathing treatments as scheduled, and nursing notes documented episodes of shortness of breath and diminished lung sounds. During interviews, the Director of Nursing confirmed the absence of documentation for the administration of these medications and acknowledged that the resident did not receive them as ordered. The attending physician also confirmed that missing several doses of these medications, especially consecutively, could trigger a COPD exacerbation. Facility policy required medications to be administered in accordance with prescriber orders, but this was not followed in this case.
Failure to Notify Physician of Abnormal Lab and Diagnostic Results
Penalty
Summary
The facility failed to verify receipt or follow up with the attending physician or nurse practitioner regarding abnormal laboratory and diagnostic results for a resident who exhibited signs of infection. The resident, who had a history of chronic obstructive pulmonary disease, emphysema, respiratory failure with hypoxia, recurrent pneumonia, and aneurysm, was admitted with significant cognitive impairment and was dependent on staff for all care. Orders were placed for a chest x-ray and laboratory tests due to respiratory symptoms, and results showed an elevated white blood cell count and abnormal chest x-ray findings suggestive of an infectious process. Despite these abnormal findings, there was no documented evidence that the physician or nurse practitioner was notified of the results. The results were faxed and texted by the RN to the nurse practitioner and physician, but there was no confirmation of receipt or response. Interviews revealed that the nurse did not verify whether the results were received and did not follow up with the physician. The physician and nurse practitioner both stated they never received the results, and the facility did not have the correct contact information for text communication. The facility's policy required direct communication and documentation of physician notification, especially in cases of significant change in condition, but this was not followed. The lack of communication and verification resulted in the resident not receiving necessary medical intervention for the abnormal findings. The resident subsequently experienced a significant decline, was found unresponsive, and was pronounced deceased. There was no documentation of a change in condition report or assessment related to the abnormal laboratory or diagnostic results, and the required notification procedures were not followed as outlined in the facility's policies.
Failure to Timely Document Medication Administration for Resident with Respiratory Conditions
Penalty
Summary
A deficiency occurred when licensed nursing staff failed to document medication administration for a resident with significant respiratory conditions, including COPD, emphysema, respiratory failure with hypoxia, and recurrent pneumonia. The resident was dependent on staff for all care and required multiple inhaled medications as part of their treatment plan. The Medication Administration Record (MAR) and audit reports revealed that documentation of medication administration was not completed at the time medications were given, but instead was entered days or even weeks later, often only after audits identified missing entries. The audit of the resident's MAR for December showed numerous instances where scheduled medications were administered at times different from those ordered, and documentation was delayed until prompted by the facility's Medical Records Assistant (MRA). Interviews with the involved LVNs confirmed that they could not recall specific details about medication administration for the resident, including which medications were given or the exact times of administration. The LVNs admitted to documenting medication administration retroactively after being notified of missing documentation during audits, rather than at the time of administration as required by facility policy. The facility's policy stated that staff must document medication administration immediately after giving each medication and before administering the next one. The DON confirmed that timely documentation is necessary for accurate monitoring of medication effectiveness and adverse reactions. However, the practice observed was that documentation was completed only after audits identified missing entries, and there was no contemporaneous record of medication administration or reasons for late documentation in the resident's progress notes.
Staff Competency Deficiencies in CPR and Emergency Equipment Use
Penalty
Summary
The facility failed to ensure that four of five staff members observed and interviewed demonstrated the competencies needed to respond to an emergency and perform CPR in accordance with facility policy and CPR guidance. During a concurrent observation and interview, CNA 1 stated that if a resident was found unresponsive, he would check chest rise and a pulse on the neck for two minutes before starting chest compressions, and he did not know the correct compression rate. CNA 2 stated that she would check for chest rise and a pulse for thirty seconds before starting CPR and was not sure how fast compressions should be performed. CNA 2 was also observed checking the carotid pulse with two fingers before performing compressions. RN 1 was observed reviewing the emergency crash cart but stated she had not checked it that day. When asked to demonstrate emergency equipment use, RN 1 stated she did not know where the adult oxygen masks, suction catheters, short and long connective tubing, CPR mask/shield, or PPE were located in the crash cart. She also stated she did not know how to connect, turn on, or determine whether the suction machine was operable, and she did not know how to check whether the oxygen tank was operable or contained oxygen. RN 1 further stated she did not know what pressure the suction machine should be set at and gave an incorrect CPR compression rate and depth. RN 2 was observed checking the crash cart and stated she did not know the location of the suction catheters and CPR masks/shields within the cart. She stated the suction device should be set at 200-300 mmHg, while the facility policy for suctioning the upper airway indicated a negative pressure of 10-15 mmHg. The DSD also failed to demonstrate proficient chest compressions, stating the count rate as 1 one thousand through 30 one thousand, and stated that during mock code drills staff performed 30 compressions to 2 breaths using an ambu-bag for two minutes. The DSD stated there was no documented evidence that the competencies and understanding of the LNs and CNAs were evaluated for the training provided during the mock Code Blue drills.
Failure to Protect Residents from Physical Abuse During Behavioral Incident
Penalty
Summary
Facility staff failed to protect two residents from physical abuse when an agitated resident, with a documented history of behavioral disturbances and aggression, was left unattended in a shared room with two other residents. The agitated resident was observed swinging two metal wheelchair footrests in the air, exhibiting aggressive behavior. A certified nurse assistant (CNA) attempted to verbally redirect the resident and remove the footrests but was unsuccessful and left the room to seek assistance, leaving the agitated resident alone with the other two residents, both of whom had significant cognitive and physical impairments. While the CNA was away, the agitated resident struck one of the roommates multiple times in the head with the metal footrests, causing severe facial lacerations, bruising, and pain. The injured resident, who was bedbound and unable to defend herself, required emergency medical attention and was transferred to an acute care hospital for evaluation and treatment of her injuries, which included a forehead hematoma, periorbital laceration, and a possible nasal bone fracture. The other roommate, also bedbound, witnessed the attack and expressed fear for her life. Interviews and record reviews revealed that staff were aware of the aggressive resident's behavioral history, including prior incidents of agitation and aggression, and that care plans specified the need for staff intervention to protect others. However, staff failed to implement appropriate interventions to ensure the safety of the roommates during the incident. The facility's policies on abuse prevention and resident safety did not provide specific guidance for managing an agitated resident in possession of a dangerous object, and staff did not utilize available methods such as overhead paging to request immediate assistance, resulting in a failure to prevent harm.
Failure to Provide Psychosocial Support After Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to provide medically related social services to support a resident's psychosocial well-being after the resident witnessed and was threatened during a violent incident involving another resident. The incident occurred when a resident with severe cognitive impairment and behavioral disturbances became agitated, removed metal wheelchair footrests, and began swinging them aggressively in a shared room. Staff attempted to intervene but were unable to de-escalate the situation before the agitated resident struck another bedbound roommate, causing visible injuries. During this event, another resident in the room, who was also bedbound and had a diagnosis of anxiety disorder and moderate cognitive impairment, was directly threatened and feared for her safety. Following the incident, the resident who witnessed and was threatened by the aggressive behavior reported experiencing fear, anxiety, and emotional distress. Despite these clear signs of psychosocial trauma, no nursing or facility staff checked on or followed up with this resident after the event. Interviews with staff confirmed that they were unaware of the resident's emotional state and had not assessed her for trauma or distress. The Director of Nursing and the Registered Nurse involved both acknowledged that the resident should have been assessed for psychosocial well-being and that the Social Services Designee should have been notified to provide support. A review of facility policy indicated that staff are responsible for identifying and addressing factors negatively affecting residents' psychosocial functioning, including resident-to-resident altercations and behavioral problems. The policy also states that social services staff are responsible for providing or arranging for mental and psychosocial counseling services as needed. In this case, the facility did not follow its own policy, resulting in a failure to provide necessary social services to a resident who experienced significant emotional distress after a violent incident.
Delayed PROM and Splint Services
Penalty
Summary
The facility failed to ensure timely implementation of physician-ordered Passive Range of Motion (PROM) services and splint application for one resident with diagnoses including contracture of the right elbow and right hand. The resident’s record showed intact cognition and capacity to understand and make decisions. A telephone order dated 9/2/2025 directed restorative nursing assistant (RNA) services for PROM to the right upper extremity every day 5 times a week during the day shift, along with application of a right elbow splint and right resting hand splint for 4 to 6 hours with skin checks every 2 hours, also 5 times a week during the day shift. The care plan included interventions for PROM and splint use for the right upper extremity. RNA documentation showed that PROM and splint services did not begin until 9/25/2025. During interviews and record review, the OTD, RNA 1, and DON all confirmed that the services should have started on 9/3/2025 and that there was a 22-day delay. RNA 1 stated she could not recall why the services were not initiated, and the DON stated the nurse receiving the order should have notified the RNA. The facility policy stated residents should receive restorative nursing care as needed and that residents with limited ROM and mobility should receive appropriate services to maintain or improve mobility unless reduction is unavoidable.
Unsafe Use of Extension Cord and Power Strip in Resident Room
Penalty
Summary
The facility failed to provide a safe, hazard-free environment by allowing an electrical extension cord and power strip to be used unsafely in a resident’s room. Resident 75 was admitted with diagnoses including intervertebral disc degeneration, urinary tract infection, and dependence on supplemental oxygen. The resident’s MDS dated 07/8/2025 showed a BIMS score of 15, indicating intact cognition, and the resident required partial to moderate assistance with tasks such as toileting hygiene, bathing, dressing, footwear, and personal hygiene. During an observation in the resident’s room, an electrical extension cord and power strip were seen placed directly on the resident’s bed, with all outlets in use. The power strip was positioned on the bed directly beside the resident’s oxygen machine and nebulizer. During interviews at the time of observation, an RN stated the extension cord and power strip should not be on the bed and were dangerous because they were a fire hazard. The Maintenance Supervisor also stated the cords should not be placed on the bed and must be on the floor, and that the facility does not keep electrical outlets or power strips on the bed because it is dangerous and a fire hazard. The facility policy on Electrical Safety for Residents stated residents will be protected from injury associated with electrical devices, including electrocution, burns, and fire, and that extension cords in use must be secured so they cannot cause trips, falls, or overheat.
Expired and Unlabeled Food Items Found in Storage; Improper Hand Hygiene Observed
Penalty
Summary
The facility failed to follow its policies and procedures for food storage, refrigerated storage, freezer storage, and employee hygiene and sanitary practices. During a kitchen tour and interview with the Dietary Service Supervisor, surveyors observed multiple expired dry food items in storage, including turmeric powder, curry powder, ground cumin, ground Italian seasoning, ground paprika, steak sauce, dry basil leaves, chili powder, dried shredded coconut, pancake mix, brown rice, cornflakes, and pepperoni slices. Surveyors also observed food items stored without required labels or dates, including scalloped potatoes, pineapple juice, instant lemon pudding removed from its original box, graham pie crusts in an opened box, frozen broccoli florets out of original packaging, an opened bag of frozen ravioli, frozen cauliflower, frozen ground pork out of original packaging, and loose cane sugar packets in a bin. During the same observation, a kitchen staff member was seen wearing gloves while rinsing dirty dishes and then using the same gloves to unload clean dishes from the sanitizing dishwasher without changing gloves or performing hand hygiene between tasks. The staff member stated hand washing and new gloves should have been used after handling dirty dishes and before handling clean dishes. The Dietary Service Supervisor stated this could allow cross contamination and that residents could get sick from dishes handled in this manner. Facility policy stated that dry foods must be labeled, dated, and not kept past expiration, frozen foods removed from original packaging must be labeled and dated, and employees must wash their hands after handling soiled equipment or utensils.
Incomplete Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to complete an informed consent for Ativan, a psychotropic medication, for one resident who had diagnoses including degenerative disease of the nervous system and major depressive disorder. The resident’s HP stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition. The resident had a physician order for Ativan 0.5 mg by mouth as needed every 6 hours for anxiety manifested by irritability and easy agitation. Review of the resident’s informed consent for psychotropic medication showed it did not include the LN’s signature or the date the consent was presented. During interview and record review, the MRA, RN supervisor, and DON all confirmed the consent form was missing the LN signature and date. They stated the signature and date were needed to verify that the consent information was received and understood by the POA, and the DON stated the facility’s policy required the informed consent to be completed before psychotherapeutic drugs were initiated.
Incomplete Advance Directive Acknowledgement and delayed resident/representative education
Penalty
Summary
The facility failed to ensure that one sampled resident and her representative were assisted to formulate an Advance Directive upon admission and that the Advance Directive Acknowledgement form was completed timely. Resident 65 was admitted with diagnoses including Parkinson's disease and hypertension, and the MDS dated 9/13/2025 indicated moderately impaired cognition and memory, with dependence in eating, oral hygiene, toileting hygiene, personal hygiene, and shower/bathe self. A review of the ADA form dated 9/15/2025 showed it was incomplete because it did not include the resident's name, attending physician, date of admission, medical records number, or facility name. The resident's responsible party did not initial statements acknowledging receipt of written material about the right to accept or refuse medical treatment, the right to formulate Advance Directives, that an Advance Directive was not required to receive treatment, or that any executed Advance Directives would be followed to the extent permitted by law. The form also did not show whether the responsible party declined or wished to execute an Advance Directive. During interview, the SSD stated she was responsible for explaining and assisting residents with ADs, but could not state whether staff explained the resident's rights during the IDT meeting or whether follow-up was required to execute the AD. The SSD later stated she contacted the responsible party and the ADA form was completed on 9/29/2025.
Failure to Develop Comprehensive Care Plan for Dental and Chewing Needs
Penalty
Summary
The facility failed to develop a baseline comprehensive person-centered care plan for a resident who had dental problems and required a change in food texture to chew effectively. The resident’s admission record showed diagnoses including hypertensive heart disease, anemia, and COPD. The MDS dated 10/3/2025 indicated moderately impaired cognition with supervision or touching assistance needed for oral hygiene and personal hygiene, and also indicated the resident required a change in texture of food or liquids while in the facility. Dental progress notes documented that the resident requested dentures to replace missing teeth for mastication, and later recommended dental x-rays, oral prophylaxis, a composite filling on tooth #22, full upper and partial lower dentures for mastication, and extraction of root fragments #20 and #21. During observation on 11/18/2025, the resident was seen with missing teeth on the upper and lower. Review of the comprehensive care plan showed no documented evidence that a care plan had been developed to address the resident’s need for dentures and chewing concerns. Staff interviews confirmed they could not find a care plan related to the resident’s teeth or dentures, and the DON stated the IDT should have developed a care plan to communicate and coordinate care for the resident’s denture issues.
Failure to Follow Up on Dental Services and Denture Needs
Penalty
Summary
The facility failed to provide medically-related social services for a resident with missing teeth and a request for new dentures. The resident had diagnoses including hypertensive heart disease, anemia, and COPD, and the admission record showed she was readmitted to the facility on 8/23/2025. The Social Service History and Initial Assessment documented that dental problems, including broken teeth and the need to see a dentist, were acknowledged by the SSD. Dental progress notes showed that the resident requested dentures to replace missing teeth and that the dentist recommended resubmitting a treatment authorization request, obtaining dental x-rays, oral prophylaxis, a composite filling for tooth #22, full upper and partial lower dentures for mastication, and extraction of root fragments #20 and #21 if dentures were to be fabricated. The resident’s MDS indicated moderately impaired cognition, need for supervision or touching assistance with oral hygiene and personal hygiene, and a change in texture of food or liquids while in the facility. The Social Service Progress Notes contained no documented follow-up regarding resubmission of the TAR, the dental recommendations, or any conversation with the resident about dentures. During observation, the resident had several missing teeth on both upper and lower gums and stated she needed new dentures to chew food and had spoken to social services and the dentist many times without response. The SSD stated she was aware of the request for dentures but did not check whether the resident was informed of the dentist’s recommendations, did not refer the recommended x-rays or schedule treatment for tooth decay, could not provide documentation of follow-up with the dentist’s clinic, did not schedule another dental appointment after the dental visit, and had not developed a care plan for the resident’s dental issues.
Failure to Provide Needed Dental Services
Penalty
Summary
The facility failed to provide necessary dental care services for one resident who had missing teeth, dental cavities, and difficulty chewing food. The resident’s record showed a history of hypertensive heart disease, anemia, COPD, and moderately impaired cognition requiring supervision or touching assistance with oral hygiene and personal hygiene. The MDS also indicated the resident required a change in texture of food or liquids while in the facility. Dental progress notes documented that the resident requested dentures to replace missing teeth for mastication and later recommended dental x-rays, oral prophylaxis, a composite filling on tooth #22 due to decay, full upper and partial lower dentures for mastication, and extraction of root fragments #20 and #21 on an emergency basis or if dentures were to be fabricated. However, social service progress notes from the resident’s stay contained no documented follow-up regarding dentures or the dentist’s recommendations. During observation, the resident was seen with missing teeth on the upper and lower and stated she had been asking the social worker and dentist for dentures for months, felt forgotten, and had not received an update. An LVN stated the resident never wore dentures and had not heard from social work that the resident asked for them. The DON stated the IDT team should have communicated better and worked together to address the resident’s denture issues.
Infection Control Lapses With Respiratory Equipment and PICC Dressing Documentation
Penalty
Summary
Provide and implement an infection prevention and control program was cited after observations, interviews, and record reviews showed infection control measures were not implemented for two residents. One resident had respiratory treatment equipment observed without a name or date on the breathing treatment mask and tubing, and the facility policy for nebulizer use required the equipment to be stored in a plastic bag with the resident’s name and the date on it, with tubing changed every seven days. The resident’s record showed diagnoses including COPD, urinary tract infection, and intervertebral disc degeneration, and the MDS indicated no significant cognitive impairment and partial assistance with activities of daily living. A second resident had a PICC line observed in the right forearm with a dressing that was not dated. During the observation and interview, nursing staff stated the PICC dressing should have a date and time to determine when the next dressing change should occur and that changing the dressing was important to prevent possible infections. The resident’s record showed admission/readmission with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, epilepsy, and heart failure, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS indicated moderate to severe cognitive impairment with decreased memory and impaired decision making requiring increased supervision and assistance with daily activities. The DON later reviewed a photograph of the PICC site and stated the dressing should include the date to indicate when the last dressing change occurred. The DON also stated that at admission, the RN is responsible for obtaining or requesting information regarding the resident’s most recent PICC dressing change, and identified the undated PICC dressing as an infection control issue. The facility’s policy for nebulizer administration required storing the equipment in a plastic bag with the resident’s name and date, and the policy for peripheral and midline IV dressing changes required maintaining sterile dressings and changing them at specified intervals.
Room Not Kept Clean and Free of Stains and Dust
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for one sampled resident by not keeping the resident’s room clean and free from stains and dust. Resident 74 was admitted on 9/1/2023 and later readmitted with diagnoses including dementia and type II diabetes mellitus. The resident’s MDS dated 8/19/2025 indicated moderately impaired cognition and memory, and the resident required setup or clean-up assistance with eating, oral hygiene, toileting hygiene, personal hygiene, and chair/bed-to-chair transfer, with supervision or touching assistance for showering or bathing. During a concurrent observation and interview on 9/29/2025 at 9:53 AM, Resident 74’s room was observed with multiple dry brown stains on the wall and dust covering the exhaust vent. The resident stated the stains were already on the wall when she moved into the room and that she had not seen anyone clean the vent; she also stated the room was not clean and she did not feel comfortable. MA 1 identified the stains as coffee stains and stated housekeeping staff were supposed to remove the stains and clean the exhaust vent cover. HK 1 stated the wall and dusty vent had not been cleaned and was unsure how long the stains had been present or when the vent cover was last cleaned. The HKS stated housekeeping staff did not clean the wall or exhaust vent cover and that housekeepers should clean every room every day and check that the wall and vent cover were clean. The facility policy titled Homelike Environment stated residents are provided with a safe, clean, comfortable, and homelike environment.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents in need. The lack of appropriate behavioral health care and services was directly observed and documented during the survey.
Failure to Develop Care Plan for Resident at Risk of Wandering and Elopement
Penalty
Summary
A comprehensive, person-centered care plan was not developed for a resident who was assessed to be at risk for wandering and elopement. The resident, admitted with diagnoses including Alzheimer's disease, dementia, and cognitive communication disease, was documented as having severe cognitive impairment and requiring moderate to substantial assistance with mobility and self-care. The resident's Elopement Evaluation indicated a risk for wandering and elopement, and staff interviews confirmed that the resident wandered around the facility and was at risk for elopement. Despite these assessments and observations, a review of the resident's active care plans revealed that no care plan had been initiated to address the behaviors of wandering or risk of elopement. The Director of Nursing acknowledged the absence of such a care plan and stated that interventions should have been included to inform staff of specific actions to take. The facility's policy required care plans to include measurable objectives, timeframes, and interventions addressing the underlying sources of problem areas, but these requirements were not met for this resident.
Failure to Develop and Communicate Individualized Behavioral Care Plan After Resident Aggression
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and sufficient staffing to address and manage the behavioral health care needs of a resident diagnosed with schizoaffective disorder-bipolar type and psychotic disorder. After an incident in which the resident choked a CNA, resulting in a temporary involuntary psychiatric commitment, the resident was readmitted to the facility. Upon readmission, the facility did not thoroughly evaluate the resident's behavioral aggressiveness or develop and communicate individualized, comprehensive care plan interventions to all staff, despite the resident's recent history of violent behavior. Documentation and interviews revealed that the interdisciplinary team (IDT) did not discuss or document the resident's aggressive behavior or history of violence in the care plan or IDT notes. Progress notes following the resident's readmission indicated further episodes of verbal and physical aggression, but no individualized behavioral interventions were developed or implemented to prevent further incidents or protect staff and other residents. Staff assigned to supervise the resident were not provided with specific care plans or instructions on managing the resident's behaviors, only general directions to keep the resident safe and prevent fights. This lack of individualized assessment, care planning, and communication led to another serious incident in which the resident, while unsupervised, obtained a bread knife, threatened staff, and acted violently in the facility lobby. The resident's roommate and other cognitively impaired residents were placed at risk during these events. Facility policies required comprehensive, person-centered care plans and thorough behavioral assessments, but these were not followed, as evidenced by the absence of specific interventions and monitoring for the resident's aggressive behaviors.
Failure to Timely Report Resident-to-Resident and Resident-to-Staff Abuse
Penalty
Summary
The facility failed to immediately report two separate incidents involving abuse and physical altercations between residents and a staff member. On the morning of 5/3/2025, one resident verbally abused another by yelling profanity, then physically pushed the other resident's wheelchair, spun him around, and grabbed his jacket. Multiple staff members and a housekeeper witnessed the incident, and the affected resident reported feeling upset, sad, and discouraged. Despite being reported to the charge nurse and witnessed by several staff, the incident was not reported to the abuse coordinator, ombudsman, police, or the state health department as required by facility policy. Later the same day, the same resident attacked a Certified Nurse Assistant (CNA) by choking her in another resident's room. This incident was witnessed by a family member, who intervened and reported the event to facility leadership. The police were called, and the resident was transferred to a general acute care hospital under a 5150 psychiatric hold. The facility's progress notes documented the physical aggression, but the incident was not reported to the appropriate authorities within the required timeframe. Interviews with staff, including CNAs, LVNs, and the Director of Nursing, confirmed that both incidents met the facility's criteria for abuse and should have been reported immediately, but were not. The facility's policies require all allegations of abuse or mistreatment to be reported promptly, no later than two hours if abuse is involved. The failure to report these incidents resulted in emotional distress for the affected resident and had the potential for recurrence and harm to other residents and staff.
Inadequate Staff Training Leads to Resident Elopement
Penalty
Summary
The facility failed to provide sufficient nursing staff with the necessary knowledge, training, and skills to address the behavioral healthcare needs of a resident diagnosed with dementia and assessed at high risk for elopement. The resident, who had a history of elopement and was known to exhibit wandering behavior, was not adequately monitored or assisted according to their care plan. On the evening of 11/27/2024, the resident became agitated and refused to re-enter the facility after being out on pass with a family member. Despite the resident's care plan indicating the need for frequent monitoring and intervention in cases of behavioral problems, the staff did not take appropriate action to address the situation. The Registered Nurse (RN) on duty failed to implement the resident's care plan, which included interventions such as speaking in a calm manner, diverting attention, and removing the resident from the situation to an alternate location if necessary. Instead, the RN instructed the family member to follow the resident and contact law enforcement, rather than sending facility staff to intervene. As a result, the resident was missing for two and a half hours before being found by local law enforcement and subsequently placed on a 72-hour hold due to being a danger to themselves. Interviews with facility staff revealed a lack of awareness and training regarding the resident's elopement risk and behavioral needs. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) were not fully informed of the resident's high elopement risk, and the Director of Nursing (DON) acknowledged that the facility did not have a competency checklist for dementia care. The facility's policy and procedures indicated that staff should be trained to support residents in distress, but the deficiency in staff training and intervention contributed to the resident's elopement and subsequent hospitalization.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for a resident with severely impaired cognition and memory, who was assessed at high risk for elopement due to dementia. The resident, admitted on 10/23/2024, had a history of elopement attempts and expressed a desire to leave the facility. Despite being equipped with a wander guard, the resident managed to elope from the facility on 11/14/2024, and as of 11/15/2024, had not been found by the facility staff. The incident occurred when the receptionist, responsible for monitoring the lobby area, left his post to use the restroom without ensuring coverage. The receptionist had previously observed the resident sitting in the activity room with a packed plastic bag, indicating a potential attempt to leave. The facility's video footage confirmed that the receptionist was absent from his post when the resident exited the facility without supervision. The wander guard alarm did not activate, and the receptionist was unsure if the resident was wearing the device at the time of elopement. Interviews with facility staff, including the LVN, ADON, and DON, revealed that the receptionist did not follow protocol to find coverage before leaving his post, contributing to the resident's unsupervised departure. The facility's policies emphasized the importance of resident supervision and safety, but these were not adequately implemented, resulting in the resident's elopement and subsequent police involvement to locate the resident.
Failure to Provide Resident Access to Medical Records
Penalty
Summary
The facility failed to provide a resident with access to personal and medical records upon request, violating the resident's rights. Resident 1, who was admitted with a primary diagnosis of polyneuropathies and had moderate cognitive impairment, requested a copy of her medical records in August 2024. Despite having the capacity to understand and make decisions, Resident 1 did not receive the medical release form necessary to obtain her records. The facility's policy required that residents have access to their records within 5 days of a request, but this was not adhered to. Interviews revealed that the Administrator instructed the Medical Records Staff to provide the release form to Resident 1 but did not follow up to ensure it was done. The Medical Records Staff claimed that Resident 1 later expressed disinterest in obtaining her records, a statement that Resident 1 denied. The staff did not document this alleged change of mind. The facility's policy and procedure on resident rights and release of information were not followed, leading to the deficiency in providing the resident access to her medical records.
Inaccessible Survey Binder
Penalty
Summary
The facility failed to ensure that the survey binder containing past survey results was accessible and available to all residents, including those who attended the resident council meeting. This deficiency was identified during interviews, observations, and record reviews. Residents expressed their lack of awareness regarding the availability and location of the survey report and the corrective actions taken by the facility. The Director of Nurses (DON) acknowledged the importance of making the survey binder accessible, but during an observation, the binder could not be located in its designated place. The report highlights that the survey binder was taken by the Medical Record (MR) staff to her office and was not returned, leading to its inaccessibility. The facility's policy and procedure on Resident Rights, which guarantees residents the right to examine survey results, was not adhered to. This oversight had the potential to leave residents and their legal representatives uninformed about the facility's past deficiencies and the measures taken to address them.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Sets (MDS) for four sampled residents were completed within the required time frame. The MDS Nurse acknowledged that the assessments for Residents 2, 30, 60, and 77 were completed late, with delays ranging from 27 to 33 calendar days past the deadline. The MDS Nurse attributed the delays to a backlog of assessments that she was unable to complete on time. The Director of Nurses (DON) was aware of the late assessments and expressed concern that delays could prevent timely updates to care plans if there were changes in the residents' conditions. The facility's policy and procedure, revised in July 2017, mandates that MDS assessments be completed and submitted in accordance with federal and state timeframes, specifically within 14 calendar days following the Assessment Reference Date (ARD). However, this policy was not adhered to, resulting in the identified deficiency.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four of five sampled residents, leading to deficiencies in care. Resident 58, who was diagnosed with dementia, schizophrenia, and anxiety disorder, did not have a care plan addressing their dementia. This oversight was confirmed during a review of the resident's records and interviews with the LVN and DON, who acknowledged the absence of a care plan for dementia, which is crucial for guiding staff in providing appropriate care and interventions. Residents 3 and 70, both receiving psychoactive medications, also lacked care plans to address the use of these medications. Resident 3, diagnosed with schizoaffective disorder and dementia, was receiving Olanzapine without a corresponding care plan to guide staff on monitoring and managing potential side effects. Similarly, Resident 70, who was on multiple psychotropic medications for dementia and psychotic disorder, did not have a care plan detailing interventions for safe medication management. Interviews with nursing staff highlighted the importance of such care plans in ensuring resident safety and effective monitoring of medication effects. Resident 63, diagnosed with COPD and bronchiectasis, refused to place their nasal cannula in a bag when not in use, yet this behavior was not addressed in their care plan. Despite having the mental capacity to make medical decisions, the resident's preference was not documented or planned for, as confirmed by interviews with the DON and observations. The facility's policy requires comprehensive care plans to be developed within a specific timeframe, but this was not adhered to, resulting in potential risks to resident care and safety.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents, leading to several deficiencies. Resident 258 and Resident 63, who were receiving oxygen therapy, did not have oxygen in use warning signs posted on their doorways, which is against the facility's policy. This oversight was confirmed by interviews with staff, who acknowledged the importance of such signage due to the presence of smokers in the facility, which could pose a fire hazard. Resident 258 was also receiving oxygen therapy without a physician's order since admission, which was a significant oversight. The lack of a physician's order for oxygen administration was confirmed during interviews with the nursing staff and the Director of Nursing (DON), who acknowledged that oxygen is a drug and should have a physician's order prior to administration to prevent potential oxygen toxicity. Additionally, the facility failed to store and change nebulizer equipment for Residents 26 and 55 according to policy. Resident 26's nebulizer mask was found stored unsanitarily in a drawer without a protective bag, posing a risk for respiratory infection. Similarly, Resident 55's nebulizer mask was not changed every seven days as required, which was confirmed by the Infection Preventionist and the DON, indicating a risk for infection due to prolonged use of the same equipment.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and distribution practices, which placed residents at risk for foodborne illnesses. During an inspection, several open food items were found without labels or open dates, including a liquid whole egg carton, apple sauce, cottage cheese, sliced watermelon, buttermilk ranch dressing, and sliced potatoes. The facility's policy requires that newly opened food items be labeled with an open date and a use-by date, which was not adhered to. Additionally, expired food items such as Parmesan cheese, turkey salad, nutmeg, and turmeric were found in the kitchen, contrary to the facility's policy that no food should be kept beyond its expiration date. The facility also failed to maintain proper sanitation practices. The Sanitizer Bucket Log, which is supposed to be filled out after each meal and use, had missing entries for several dates, indicating that the kitchen was not sanitized according to the facility's policy. The Dietary Service Supervisor (DSS) acknowledged the missing entries and stated that it was the responsibility of the kitchen staff to complete the log. Furthermore, the Ice Machine Cleaning Log and the Cleaning and Maintenance Schedule Log had multiple missing entries, indicating a lack of consistent monitoring and documentation of cleaning practices. The DSS admitted to not following up with the staff to ensure that logs were filled out accurately and consistently. The facility's policy requires the Food and Nutrition Services Director to write a cleaning schedule designating tasks by job title or employee, which was not effectively implemented. These deficiencies in food storage, expiration monitoring, and sanitation practices highlight a significant lapse in maintaining sanitary conditions in the facility's kitchen, potentially exposing residents to health risks.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its infection control program for six sampled residents, leading to several deficiencies. For Resident 258, the nasal cannula, handheld nebulizer circuit, and oxygen humidifier were not labeled with the date of initial use, and the nebulizer circuit was not stored in a plastic bag. This oversight was confirmed by interviews with the LVN, RN, and Infection Preventionist Nurse, who acknowledged that the lack of labeling and proper storage could lead to the equipment harboring bacteria and viruses, potentially spreading infections. Resident 86's feeding syringe was not changed every 24 hours as required, which was confirmed during an observation and interview with the Director of Staff Development. The syringe, used for flushing the G-tube and administering medications, was found to be unchanged for two days, increasing the risk of infection. The Director of Nursing confirmed that the facility's policy required the syringe to be changed daily to prevent infection. For Resident 55, the blood pressure monitor was not cleaned and disinfected before and after use, as observed during a nurse's routine check. This practice was against the facility's policy, which mandates disinfection of reusable equipment between uses to prevent infection spread. Additionally, staff failed to perform hand hygiene while distributing meal trays to Residents 43 and 257, as observed during meal service. The CNA admitted to not washing hands between assisting the two residents, which was against the facility's hand hygiene policy designed to prevent cross-contamination.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications prescribed to a resident, identified as Resident 99, who was receiving Quetiapine and Zolpidem. The resident was admitted with diagnoses including dementia, psychotic disorder, and cognitive communication deficit, and was noted to have severely impaired cognitive status. Observations and interviews revealed that the resident was confused and agitated, and staff redirected the resident's attention as needed. However, the facility did not have a documented informed consent for the psychotropic medications, which is required by their policy. Interviews with the Director of Staff Development and the Director of Nurses confirmed that the informed consent for the psychotropic drugs was not obtained as per policy, which requires a physician to explain the medications' effects and alternatives to the resident or their responsible party. The facility's policy mandates that informed consent should be documented with the physician's signature, which was missing in this case. This oversight violated the resident's rights to be informed and involved in their care decisions, as outlined in the facility's policies on informed consent and resident rights.
Failure to Provide Communication Board for Resident
Penalty
Summary
The facility failed to provide a communication board for a resident with significant communication challenges, resulting in the resident's needs not being effectively communicated or met. The resident, who had been admitted with conditions including hemiplegia, hemiparesis, aphasia, and cognitive communication deficits, was recommended by a Speech-Language Pathologist to use a communication board to facilitate communication. Despite this recommendation, the resident was observed struggling to communicate her needs during meal times, as staff members were unable to understand her gestures and nonverbal cues. Multiple staff members, including CNAs, were observed attempting to guess the resident's needs without the aid of a communication board, leading to prolonged periods of misunderstanding and frustration for the resident. Interviews with staff revealed that they were unaware of the existence of communication boards in the facility, despite the Director of Nurses stating that such tools were available. The facility's policy on accommodating individual needs emphasized the importance of promoting communication and maintaining dignity, which was not upheld in this case.
Failure to Assist Resident During Mealtimes
Penalty
Summary
The facility failed to provide necessary assistance to a resident during mealtimes, which led to the resident's inability to eat independently. The resident, who was admitted with conditions including hemiplegia, hemiparesis, and dysphagia, required supervision and assistance with eating due to right-side weakness. Despite these needs being documented in the resident's care plan and nutritional screening, the resident was observed eating alone without assistance, struggling to cut and consume a piece of chicken. The resident's inability to reach the fork and use her right arm was evident, and no staff was present to assist her during the meal. The deficiency was further highlighted when a CNA confirmed that the resident should have been assisted during mealtimes, as the chicken was too large for her to manage independently. The CNA acknowledged the resident's right-side weakness and the necessity for assistance in cutting the food into manageable pieces. The Director of Nurses also confirmed that the resident should have received assistance during meals to prevent potential risks such as malnutrition and weight loss. The facility's policy on supporting activities of daily living, including dining assistance, was not adhered to in this instance.
Incorrect LAL Mattress Settings for Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident with skin breakdown and pressure injuries by not ensuring the correct settings on a low air loss mattress (LAL Mattress). The resident, who was admitted with diagnoses including COPD, muscle weakness, and generalized osteoarthritis, was totally dependent on staff for daily activities and had severe cognitive impairment. Despite the resident's weight being recorded as 204 pounds, the LAL Mattress was incorrectly set for a person weighing 550 pounds, which was observed during a facility visit. The Treatment Nurse confirmed that the mattress settings were incorrect and should have been set at 250 pounds based on the resident's actual weight. The incorrect settings made the mattress too hard, potentially preventing wound healing and increasing the risk of further skin breakdown. The manufacturer's manual for the mattress indicated that the air pressure should be adjusted based on the patient's weight and comfort levels, which was not adhered to in this case.
Failure to Provide Appropriate Rehabilitation Services and Devices
Penalty
Summary
The facility failed to provide appropriate rehabilitation services and devices to maintain or improve mobility for a resident with limited mobility and contractures in both arms. The resident, who was admitted with diagnoses including dementia, schizophrenia, and anxiety disorder, was observed with rolled towels placed between their contracted arms instead of the recommended splints. The resident's care plan indicated limitations in shoulders, elbows, and fingers, with interventions to prevent further contractures using pillows or splints. However, the use of rolled towels was not effective or recommended by the facility's physical therapist and rehabilitation director. The physical therapist and rehabilitation director both stated that splints should have been used to prevent further contractures, as rolled towels are not a standard practice and are not therapeutic. The resident had not been referred to rehabilitation for reassessment since 2021, despite the need for appropriate devices to prevent further decline. The Director of Nurses confirmed that towels were inadequate for preventing contractures and acknowledged the need for reevaluation. The facility's policy indicated that residents with limited ROM should receive appropriate treatment and services to prevent further decrease, which was not adhered to in this case.
Failure to Maintain Safe Environment for Residents
Penalty
Summary
The facility failed to ensure a safe and hazard-free environment for two residents, leading to potential risks. For Resident 87, the bed alarm, which was intended to monitor the resident's movements and prevent falls, was found to be non-functional. The bed pad sensor was not connected to the bed alarm monitor, and the monitor's light was off, indicating it was not operational. Certified Nursing Assistants (CNAs) acknowledged the malfunction and admitted to not checking the alarm due to being occupied with other duties. This oversight placed Resident 87, who has dementia and muscle weakness, at risk of falls when attempting to get out of bed without assistance. Resident 63, who is a smoker and receives oxygen therapy, was found to have a bag of tobacco at the bedside, which is against the facility's policy. The resident, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and bronchiectasis, was observed with tobacco and a pipe in his room, despite being on oxygen therapy. The Social Worker Designee and Registered Nurse Supervisor confirmed the presence of tobacco and acknowledged that it was not safe for the resident to have smoking materials in the room due to the risk of fire. The facility's policies clearly state that residents on oxygen therapy should not have smoking materials in their possession or in their rooms. The Director of Nursing reiterated that smoking materials should be managed by the activities staff and not kept with residents, especially those on oxygen therapy. The failure to adhere to these policies posed a significant safety risk to Resident 63 and others in the facility.
Failure to Verify Resident Identity Before Medication Administration
Penalty
Summary
The facility failed to verify the identity of a resident before administering medication, which was not in accordance with the facility's policy and procedure. The incident involved a resident who was admitted with diagnoses including diabetes mellitus and hypertension. The resident had moderately impaired cognitive skills and required varying levels of assistance with daily activities. On the day of the incident, the resident was administered a multivitamin-mineral tablet without proper identity verification. The Licensed Vocational Nurse (LVN) responsible for administering the medication did not use the required identifiers to confirm the resident's identity. The resident did not have an identification band, and there was no profile picture available in the electronic health record (EHR). The LVN only called the resident's last name, which was insufficient according to the facility's policy. The Director of Nursing confirmed that the facility's policy required multiple identifiers, such as an ID band, photograph, and verification with other personnel, to prevent medication errors.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications, as required by their policy and procedure. Resident 58, diagnosed with schizophrenia and depression, was prescribed Risperidone and Trazodone without adequate monitoring or documentation of the behaviors that warranted their use. Despite being nonverbal and bedbound, the resident was noted to have no specific episodes of behavior that justified the continued use of these medications. The facility's staff did not properly track or document the resident's behaviors, which prevented the assessment needed to initiate a gradual dose reduction (GDR). The Director of Nurses (DON) acknowledged that the indications for the medications were not specific enough and that the facility's consultant pharmacist's recommendations for GDR were not adequately reviewed or acted upon. Resident 4 was administered Lorazepam without a physician's order, which is a violation of the facility's medication administration policy. The resident, who had severe cognitive impairment, was given Lorazepam on multiple occasions after the original order had expired. The nursing staff failed to obtain a new order before administering the medication, and there was no documentation in the Medication Administration Record (MAR) to support the administration of Lorazepam. The DON confirmed that the medication should not have been given without a valid order and that the resident should have been reassessed for the need for Lorazepam. The facility's policies on psychoactive drug monitoring and antipsychotic medication use were not followed, leading to the inappropriate use of psychotropic medications for both residents. The lack of specific documentation and monitoring of behaviors, as well as the failure to reassess the need for continued medication use, contributed to the deficiencies identified by the surveyors. The facility's failure to adhere to its own policies and federal regulations put the residents at risk for unnecessary medication use.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as observed during a survey. In the medication room, the thermometer was not functioning, and the temperature was not recorded in the Daily Room Temperature Log, which is essential to maintain the potency of medications. The Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD) confirmed that the temperature was not documented, and the thermometer was not working, indicating a lapse in monitoring the medication storage conditions. Additionally, the facility did not label multi-dose medication bottles with the resident's name, as required. For Resident 257, who was admitted with hypertension and muscle weakness, opened bottles of Ascorbic acid, Vitamin E, and Vitamin D3 were found in the medication cart labeled only with the room number. The LVN acknowledged that the resident's name should have been on the bottles to prevent medication errors, especially if the resident was moved to a different room. Furthermore, the facility failed to label opened multi-dose bottles with the open date, which is crucial for determining the expiration of liquid medications. LVN 7 observed that bottles of Pro-Stat, bismuth subsalicylate, Geri-Lanta, and sterile normal saline were not labeled with the open date. The Infection Preventionist (IP) and the Director of Nursing (DON) emphasized the importance of labeling to ensure medication potency and prevent infection. The facility's policy and procedure on medication labeling and storage, dated February 2023, required medications to be stored under proper conditions and labeled with the resident's name and the open date for multi-dose vials.
Failure to Provide Correct Diet Texture for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of a resident with dysphagia, who was ordered by the physician to be served a regular diet with mechanical soft texture. Despite the physician's order, the resident received regular texture food instead of the required mechanical soft texture from July 16, 2024, to October 3, 2024. This oversight placed the resident at risk for aspiration and choking. The resident, who was initially admitted on April 1, 2015, and readmitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, cognitive communication deficit, aphasia, and dysphagia, had a care plan indicating a risk for aspiration and choking during meals. The care plan included interventions such as a mechanical soft diet with thin liquids and assistance during meals. However, during a dining observation on October 1, 2024, the resident was seen eating alone with no assistance and using a spoon to cut a large piece of chicken, indicating a failure to adhere to the prescribed diet texture. Interviews with facility staff revealed that the Dietary Service Supervisor was unaware of the mechanical soft texture order due to an error in transferring the diet order into the system, resulting in the resident receiving a regular texture diet. The Director of Nurses confirmed that the resident's diet order had been mechanical soft texture since July 16, 2023, and acknowledged the risk of aspiration or choking due to the incorrect diet texture being provided.
Failure to Timely Screen and Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to screen and offer the pneumococcal vaccine to a resident upon their initial admission, as required by the facility's policy. The resident, who was admitted with diagnoses including depression and low back pain, had moderately impaired cognitive skills and required varying levels of assistance with daily activities. The facility's policy mandates that assessments of pneumococcal vaccination status be conducted within five working days of admission. However, the Infection Preventionist (IP) did not screen the resident for the vaccine until 22 days after admission due to being occupied with other tasks. During interviews, both the IP and the Director of Nursing acknowledged the oversight. The IP admitted to not screening the resident in a timely manner, which delayed informing the resident about the vaccine and its protective benefits against pneumonia. The Director of Nursing confirmed that staff should screen residents for the pneumococcal vaccine upon admission to ensure they are informed and offered the vaccine to protect against pneumococcal infection.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glenhaven Healthcare | 0.4 mi | ★★★★★ | 14 | 0 |
| Glendale Healthcare Center | 0.5 mi | ★★★★★ | 10 | 0 |
| Broadway Manor Care Center | 0.8 mi | ★★★★★ | 18 | 0 |
| Royal Palms Post Acute | 0.8 mi | ★★★★★ | 35 | 0 |
| Leisure Glen Post Acute Care Center | 1 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.