Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Colonial Care Center during CMS and state inspections, most recent first.
Overflowing and Uncovered Dumpster Area: Surveyors observed three outdoor dumpsters that were open and overflowing with garbage, including folded boxes and bags of used PPE spilling onto nearby bin lids. Two dumpster lids were not completely closed during a follow-up observation, and the DSS stated dumpsters should not be overfilled and should be kept closed to prevent pests. The facility policy required outside garbage bins to remain closed and surrounding areas to stay clean.
A resident with dementia, cataracts, and severe visual impairment had documented need for supervision with toileting and ambulation, but staff did not consistently supervise her or update her care plan after repeated falls. After an unwitnessed bathroom fall, the resident had hip and groin pain and was later found to have a right pubic ramus fracture of unknown age; staff did not complete a COC, notify the MD, or re-evaluate interventions despite the resident’s ongoing falls and worsening vision.
A resident with ESRD receiving hemodialysis had an incomplete fluid restriction order that only limited a water pitcher at the bedside, without a specified 24-hour fluid allowance. Staff also confirmed there was no order for intake measurements and no documentation of the resident’s fluid intake, despite facility policy calling for specific fluid orders and intake recording when ordered.
Failure to provide trauma informed and culturally competent care occurred when the facility did not identify or document trauma triggers for two residents with PTSD and other mental health diagnoses. One resident’s care plan for trauma related to a disaster did not identify the nature of the trauma or triggers, and the SSA said the assessment lacked needed information. Another resident reported a history of homelessness and assault, stated that unexpected close contact triggered him, and described nightmares and sleep difficulty, but his TCE also showed no trauma or triggers identified and staff said the care plan was not person centered or individualized.
Two residents had bilateral bed rails installed without complete informed consent and without clear documentation of alternative attempts before use. One resident had impaired cognition with bipolar disorder, Alzheimer’s disease, and Parkinson’s disease, and the other had dementia, schizophrenia, and a history of falls. Staff interviews and record review showed missing consent details, lack of second-nurse verification, and incomplete documentation related to the bed rail assessments and installation.
Medication Error Rate Exceeded 5%: An LVN administered the wrong strength of ferrous sulfate to two residents and gave one resident the wrong multivitamin formulation, resulting in a 10.34% medication error rate. The residents’ records showed dementia in one resident and cerebral infarction in the other, and the LVN stated he did not verify the medication formulation against the physician’s order before administration.
Food Storage and Sanitation Deficiencies: Open corn tortillas were found stored uncovered and one lacked an open date, an open package of dried pasta was left open to air, and a dented can was stored with other cans. In addition, trash bins in the kitchen area were uncovered or had broken lids, three cutting boards had visible cut marks, and wet pans were stacked before being fully air-dried, contrary to the DSS’s statements and facility P&P.
Failure to Follow Linen Handling and EBP: CNA 2 handled a resident's hoodie after it fell on the hallway floor and placed it in a closet with clean clothes instead of treating it as contaminated linen. In a separate event, a CNA changed a resident's dirty bed linens without wearing the gown and gloves required by EBP, even though the EBP sign was posted and PPE was available. The DON and IPN confirmed the infection control lapses, and facility policies required contaminated linen to be handled to prevent contamination and EBP PPE to be worn for high-contact care.
Incomplete Informed Consent for Padded Side Rails: A resident with severe cognitive impairment, tracheostomy, gastrostomy, and diabetes had padded bilateral upper side rails used while in bed, but the written informed consent was not completed. The form lacked signatures from the prescribing physician, resident representative, and verifying nurse, and an LVN stated she forgot to ensure the consent was completed. The DON confirmed padded side rails require informed consent and that staff did not follow policy.
Advance Directive and POLST Not Completed: A resident with dementia, encephalopathy, bipolar disorder, and no decision-making capacity had a DNR POLST that was left incomplete, with the AD section blank. The SSA documented telephone consent from the RP for DNR, selective tx, no feeding tube, and no AD, but stated she did not provide written AD materials, did not complete/update the POLST, and did not have the required witness during the telephone consent process. The DON stated AD and POLST should be available for all residents and that staff should have ensured completion and written information.
Failure to notify physician of tube feeding refusal: A resident with quadriplegia, acute respiratory failure, and a gastrostomy tube refused tube feeding, and an LVN turned off the pump and flushed the tube without notifying the primary physician. The resident's tube feeding order was for Jevity 1.5 via pump, and the RD and DON stated the refusal should have been reported and documented.
MDS assessments did not accurately reflect bed rail use for two residents. One resident with bipolar disorder, Alzheimer's disease, and Parkinson's disease, and another resident with dementia, schizophrenia, and a history of falls, were both observed in bed with bilateral side rails up while their orders described low beds with bilateral quarter rails as enablers for mobility and ADLs. The MDS nurse and ADON stated the assessments should have captured the bed rail use.
Failure to Follow Fall Care Plan Interventions: A resident with dementia, schizophrenia, and a hx of falls had impaired cognition and needed max assist with several ADLs. Staff observed the resident in bed with siderails up and the call light within reach, but no floor mats or bed alarm were in the room. The care plan included a Falling Star Program with floor mats, a bed/chair alarm, and IDT conferences, but an LVN stated the plan was not updated to reflect current needs and the facility did not follow the planned interventions.
Failure to Follow Pain Care Plan Interventions: A resident with HTN, schizophrenia, low back pain, and cognitive impairment reported recurrent right shoulder pain and said only pain meds had been offered, though he was interested in a hot pack and other alternatives. The care plan included nonpharmacological interventions such as hot/cold packs, massage, and distraction, but an LVN stated these were not offered because the resident usually had a lidocaine patch, and an RN found no documentation that nonpharmacological pain interventions were implemented.
An LVN failed to use behavioral signs of pain when a resident with cognitive impairment and schizophrenia could not provide a numeric pain score. The resident yelled that he was in pain, but the LVN documented pain as 0/10 and later stated the assessment was inaccurate. The DON confirmed nurses are expected to assess pain each shift and use behavioral cues when residents cannot verbalize their pain level.
Failure to Provide Ordered RNA Services: A resident with schizophrenia, dementia, and DM was ordered RNA services including PROM to BUE and BLE and soft hand rolls, but the documentation showed multiple NA entries for those services. During observation, the resident stated he could not use his hands and was not able to use his wheelchair as before, and he was unsure whether he was receiving RNA services. RNA staff and the DON stated that if the services were not documented, they were not provided as ordered.
A resident with a gastrostomy tube and persistent vegetative state did not receive ordered Jevity 1.5 tube feeding when the pump was observed off, then later on but not infusing, with the formula bottle still full. The LVN said the pump had been turned on at noon but did not know why it was not delivering feeding until troubleshooting began. The RD and DON confirmed the resident had gone over three hours without tube feeding, and the facility policy required enteral nutrition to be provided as ordered.
Two unopened Humalog insulin pens for two residents were found in a med cart at room temperature instead of being refrigerated per the manufacturer’s labeling. An LVN stated the pens were kept at room temperature and were not labeled with an open date, and noted that without an open date staff could not accurately determine when the insulin expires. The facility policy required medications and biologicals to be stored according to manufacturer recommendations, with refrigerated meds kept in a refrigerator with a thermometer.
Missed Weekly Hospice RN Visit: A resident under hospice care with dementia-related diagnoses and total dependence for many ADLs did not have documentation of the required weekly hospice RN visit. The patient calendar and hospice communication record showed no evidence of the scheduled RN visit, and the RNS and DON stated facility staff did not follow up with hospice to ensure the agreed-upon weekly hospice assessment occurred.
A resident with dementia and agitation pushed a roommate after the roommate entered her unlocked closet and handled her belongings, causing the roommate to fall and sustain a head laceration that required ED treatment. Staff reported the closet locks did not work, the room closets were supposed to remain locked, and the injured resident frequently wandered into other residents’ rooms to clean or fix things, but that behavior was not monitored or care planned. The incident escalated after an earlier argument over water on the floor, and the roommate was later diagnosed with assault and facial laceration.
A nurse repositioned a severely cognitively impaired, non-ambulatory resident who required a documented two-person assist for rolling, without obtaining help and without fully assessing mobility limitations as required by facility policy. The nurse used a draw sheet to move the resident, whose legs were straight and crossed, while the resident was near the edge of the bed and part of the bed frame was exposed due to incomplete mattress coverage. During the turn, the resident’s right knee struck the exposed bed frame, resulting in immediate pain, swelling, and tenderness, and subsequent imaging confirmed an acute distal femur fracture that required hospital transfer for immobilization, pain management, and monitoring.
A resident with moderate cognitive impairment and chronic medical conditions reported to an LVN that someone had pulled her hair in the hallway several days earlier. The LVN did not report the allegation to supervisory staff or the Administrator as required by facility policy, resulting in a delay in notifying authorities and initiating an investigation. The RN and Administrator confirmed that immediate reporting was necessary and that the facility's policy required notification to the State Agency within two hours of awareness.
A resident with multiple complex medical conditions experienced unmanaged severe pain and swelling after sustaining an acute femoral fracture. Facility staff delayed notifying the physician for over seven hours after receiving x-ray results confirming the fracture, and did not follow care plan and policy requirements for prompt intervention. The resident continued to experience severe pain before being transferred to a hospital, where surgical intervention was required.
A resident assessed as high risk for falls, with cognitive impairment and mobility deficits, was found in a bed that was not set to the lowest position as required by their care plan. Staff confirmed that the bed was 2 inches higher than the lowest setting, despite facility policies and daily huddles emphasizing the importance of such interventions for fall prevention.
A resident with a Full Code status did not receive immediate CPR when found unresponsive and without a palpable pulse. The RN failed to announce a Code Blue and relied on an oximeter reading instead of manually checking for a pulse and starting CPR, contrary to facility policy. This delay in initiating life-saving measures was a significant deficiency in the facility's emergency response protocol.
A resident with a gastrostomy tube experienced severe weight loss due to the facility's failure to conduct timely assessments, notify the physician and dietician, and update the care plan. The resident lost 25.8 pounds over two months, equating to 21.6% of their body weight, without adequate monitoring or intervention. The lack of communication and documentation among the care team contributed to the resident's continued weight loss, placing them at risk for malnutrition and dehydration.
The facility did not follow its sanitation and infection control policy, as observed when an RRD handled a food thermometer without hand hygiene or gloves. The RRD used an alcohol swab to clean the thermometer before inserting it into pureed broccoli, repeating the process without washing hands or using gloves. This action was contrary to the facility's policy, which requires hand washing and glove use when handling ready-to-eat foods.
The facility failed to properly store and label food, leading to potential foodborne illness risks. Observations showed improper storage of frozen meats and vegetables, undated food items, and expired products. Additionally, the facility lacked chlorine test strips for the dishwasher and a scale for portion sizes, compromising sanitation and nutritional standards.
The facility failed to properly dispose of garbage and refuse by not ensuring that two out of three dumpsters were completely covered, as observed near the kitchen area. The Dietary Manager and Maintenance Supervisor noted that the trash bin lids were not fully closed, and there were black trash bags and other waste items on the ground. This non-compliance with the facility's waste disposal policy could attract pests and pose a risk of cross-contamination for residents receiving food from the kitchen.
The facility failed to offer, educate, and track COVID-19 vaccinations for staff as per its policy, potentially placing all residents at risk. The IPN stated that the facility did not maintain a tracking log or retain records of vaccination education, proof, or declinations for staff. The DON emphasized the importance of documenting staff vaccinations. The facility's policy required education on vaccination benefits, offering vaccinations based on health department recommendations, and maintaining proof of vaccination or written declinations.
The facility did not provide mandatory Effective Communications training for its direct care staff, including RNs, LVNs, and RTs, as required by its policy. The Director of Staff Development was unaware of this requirement, resulting in the training not being conducted in 2024. The Director of Nursing highlighted the importance of this training for effectively communicating with non-English speaking residents and those with specific needs, such as dementia or stroke, to ensure their needs are met.
The facility did not provide mandatory QAPI training to its direct care staff, including RNs, LVNs, and RTs, as required by its policy. The Director of Staff Development was unaware of the requirement, leading to a lack of training in 2024. The Director of Nursing highlighted the importance of QAPI for addressing issues and ensuring proper resident care. This deficiency could result in poor communication, lack of awareness of facility updates, and compromised resident care.
The facility failed to involve two residents in their care planning processes. One resident experienced significant weight loss without a care plan involving his responsible party, while another resident's range of motion exercises were discontinued without adequate discussion or documentation. Both cases highlight deficiencies in involving residents and their responsible parties in care planning.
The facility failed to update advance directives for four residents with cognitive impairments, leading to potential conflicts with their healthcare wishes. Despite attempts to contact public guardians and family members, the directives remained incomplete, contrary to facility policies requiring annual reviews.
The facility failed to notify the physician and family of significant changes in two residents' conditions. One resident experienced severe weight loss, and the other refused range of motion exercises, both without timely notification to the physician or family. The facility's policies on change of condition were not followed, potentially delaying necessary care.
A long-term care facility failed to follow its policy on physical restraints for two residents. One resident was placed in bed with all side rails up without exploring alternatives or obtaining informed consent, while another was restrained with a lap tray in a Geri chair without proper assessment or documentation. The facility did not conduct necessary evaluations or hold interdisciplinary team meetings to ensure the appropriateness of these restraints, compromising resident safety and dignity.
The facility failed to ensure accurate PASRR assessments for two residents with serious mental health conditions, leading to potential unmet needs. One resident had diagnoses including psychosis and schizoaffective disorder, while another had major depressive disorder and dementia. Both residents' PASRR Level I screenings incorrectly indicated no serious mental illness. The ADON acknowledged the inaccuracies and the importance of the PASRR process in addressing residents' mental health needs.
The facility failed to create comprehensive care plans for nine residents, leading to unmet needs and potential negative outcomes. A resident with quadriplegia refused ROM exercises, but no care plan addressed this refusal. Another resident with epilepsy had no updated care plan for seizures and medications. Three residents experienced significant weight loss without appropriate care plans, and three others required specialized services per PASRR evaluations, but no individualized care plans were made.
The facility failed to provide appropriate treatments and services to prevent or limit a decline in ROM and mobility for five residents. A resident did not have a specified wear time for a hand splint, leading to potential skin issues. Two residents missed multiple PROM exercise sessions, risking functional decline. Additionally, two residents did not receive prescribed ambulation exercises, potentially affecting their mobility and physical functioning.
A LTC facility failed to properly manage tube feedings for three residents with gastrostomy tubes, risking infection. A resident's tube feeding was not disconnected after administration, while two others had feedings hanging beyond the recommended time, contrary to facility policy and manufacturer guidelines.
A resident experienced significant weight loss that was not properly documented or communicated to the RD, physician, or family. The facility's staff failed to follow policies for documenting and reporting weight changes, leading to a lack of timely intervention. Interviews revealed a lack of understanding and adherence to weight monitoring and reporting protocols.
The facility failed to administer medications correctly for two residents. One resident was given chewable Aspirin to swallow, contrary to the physician's order, potentially affecting its efficacy. Another resident with a gastrostomy tube received Zinc Sulfate via the tube despite the order indicating oral administration, risking aspiration. The errors were acknowledged by staff, highlighting the need for accurate medication administration routes.
The facility failed to properly store and label medications, including Budesonide, Tobramycin, Ipratropium-Albuterol, and PPD, as per manufacturer guidelines. Opened medications lacked proper dating, and expired medications were not disposed of, potentially affecting resident care. Staff acknowledged these oversights during the survey.
A facility failed to accurately document Physical Therapy Joint Mobility Screenings for a resident with quadriplegia, leading to potential miscommunication among staff. The screenings inaccurately indicated full PROM based on visual observation, despite the resident's refusal for manual assessment. This discrepancy was confirmed by the PT and highlighted by the ADON and DON, emphasizing the importance of accurate documentation to ensure appropriate care.
The facility's QAA and QAPI committees failed to identify and address concerns related to CPR and weight loss among residents. The administrator admitted these issues were not part of the current QAPI plan and were not identified before the recertification survey. The facility's QAPI program, which focuses on care outcomes and quality of life, failed to monitor indicators related to CPR and weight loss, potentially leading to continued weight loss and improper CPR assessment for full code residents.
A long-term care facility failed to follow infection control protocols, including not wearing PPE during high-contact activities with residents on Enhanced Barrier Precautions, improper wrapping of bed rails hindering disinfection, and lack of EBP signage for residents with medical devices. These deficiencies increased the risk of infection transmission among residents and staff.
The facility failed to implement its antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. One resident received ceftriaxone for a UTI without meeting criteria, and another was given cephalexin for a possible UTI, also without meeting criteria. The Infection Preventionist Nurse noted the lack of physician notification in both cases, despite the Director of Nursing's emphasis on the importance of appropriate antibiotic use.
A resident under hospice care with severe cognitive impairment did not receive necessary oral care, resulting in dried, sticky brown buildup on their teeth. Despite care plans and physician orders for oral hygiene, observations and staff interviews confirmed the lack of care, compromising the resident's dignity and health.
A resident with protein-calorie malnutrition, major depressive disorder, and dysphagia experienced significant weight loss due to the facility's failure to monitor and document assessments and interventions during a change of condition. Despite dietary interventions, the care plan was not updated to address actual weight loss, leading to the necessity of a gastrostomy tube. Staff interviews revealed inadequate communication and documentation regarding the resident's intake, contributing to the deficiency.
A resident was prescribed Seroquel, an antipsychotic medication, without a proper diagnosis or indication for its use. The resident, who had severe cognitive impairment but no signs of psychosis, was at risk for harmful side effects. The facility's policy required medications to be clinically indicated, which was not followed.
Overflowing and Uncovered Dumpster Area
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed the outdoor garbage area with three dumpsters that were open and overflowing with garbage. During the observation, folded brown boxes and trash bags filled with used PPE were overflowing from the dumpsters onto the lid of two trash bins. On a concurrent observation and interview, the Dietary Services Supervisor stated that trash dumpsters should not be overfilled and that garbage containers should be kept closed when not in use to prevent pests from getting inside. The supervisor also stated that residents could get sick from diseases that pests spread. Review of the facility's Waste Control and Disposal policy indicated that outside garbage bins should be kept closed at all times and surrounding areas must be kept clean, with garbage disposed of in a timely manner to prevent buildup.
Failure to Supervise a Visually Impaired Resident With Recurrent Falls
Penalty
Summary
The facility failed to ensure adequate supervision and fall-risk interventions for a resident with dementia, cataracts, and a history of falling who had documented severe visual impairment and needed supervision or touching assistance for toileting and personal hygiene. The resident’s care plan included assistance to the toilet or bedside commode, a safe environment, adequate lighting, and observation for decreased vision and blurring. Records also showed the resident had difficulty seeing, did not move her pupils when tested, and later reported worsening blurry vision in both eyes, with cataract surgery recommended and further ophthalmology evaluation advised. After an unwitnessed fall in the bathroom, the resident complained of right hip and leg pain and was later found to have a fracture of the right superior pubic ramus of unknown age. The report states staff did not complete a change of condition form for the unwitnessed fall, did not notify the MD, and did not update the care plan to reflect the resident’s needs after the fall. The facility’s IDT note documented the resident had fallen and had limited to maximum assistance needs, but the ADON stated no intervention or follow-up was needed because the fracture was of unknown age. The report also states the resident continued to ambulate without assistance despite worsening vision. On observation, the resident was seen sitting at the edge of the bed, trying to get up by holding onto the wall and starting to walk toward the restroom without assistance. Staff interviews indicated the resident should always have been supervised when ambulating to the restroom because of her worsening vision. The facility’s Falls and Fall Risk policy required staff to monitor and document the resident’s response to interventions and to implement additional or different interventions if falling recurred, but the report states this was not done after the resident’s repeated falls.
Incomplete Fluid Restriction and Intake Monitoring for Dialysis Resident
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for a resident with ESRD, DM, and COPD who was receiving hemodialysis. The resident’s record showed a physician order for fluid restriction that stated only “limited to no water pitcher at bedside,” and staff identified that the order did not specify the amount of fluid the resident could have in a 24-hour period. During interviews, the LVN, RN, RD, and DON all stated that the fluid restriction order was incomplete and that dialysis residents need a clear daily fluid allowance because they are at risk for fluid overload. The record also showed no physician order for intake measurements for the resident. Staff stated there was no documentation of the resident’s fluid intake in nursing progress notes, and the administration report only reflected that no water pitcher was at the bedside. The facility policy for renal dialysis indicated that fluid restriction should include MD orders for specific fluid allowed in 24 hours, and another policy stated intake should be measured and recorded each shift if ordered. Staff confirmed that the resident’s fluid intake was not being documented.
Failure to Identify Trauma History and Triggers in Two Residents
Penalty
Summary
Provide care or services that was trauma informed and/or culturally competent was not met when the facility failed to identify and intervene in the trauma history and triggers for two sampled residents. Resident 17 had diagnoses including PTSD, schizophrenia, and dementia, and the record showed he required assistance with hygiene, bed mobility, transfers, dressing, bathing, and eating. His care plan addressed trauma informed care related to a large scale natural and/or human caused disaster survivor and adjusting to a new place, but the Registered Nurse Supervisor stated the plan did not identify the nature of the trauma or the resident’s triggers, and the interventions were not individualized to prevent re-traumatization. Resident 17’s Trauma Care Evaluation, completed by the Social Service Assistant, indicated no trauma and triggers were identified. During interview, the SSA stated staff should have assessed and identified the triggers of PTSD and the severity of possible re-traumatization, and stated she could not obtain much information from the resident. She also stated she should have contacted the resident’s psychiatrist and public guardian to obtain information regarding his PTSD. The facility’s care plan therefore lacked identified triggers and individualized interventions despite the resident’s trauma-related diagnosis and documented care plan for trauma informed care. Resident 156 also had diagnoses including PTSD, schizoaffective disorder, and major depressive disorder, and required assistance with hygiene, bed mobility, transfers, dressing, bathing, and eating. The resident stated he had been homeless, was attacked suddenly, lost consciousness, and was treated at a hospital; he also stated that unexpected physical proximity, such as a nurse coming close without warning, triggered him and contributed to nightmares and sleep difficulty. However, his care plan only included general interventions such as reducing stress, monitoring behavior episodes, and providing a safe environment, and the RNS stated the plan was not person centered and lacked individualized, specific interventions. The resident’s Trauma Care Evaluation again indicated no trauma and triggers were identified, and the SSA stated the assessment was important because care would differ based on the findings and that the resident’s care plan was not person centered because no trauma assessment was done.
Incomplete consent and missing alternative attempts before bed rail use
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before bilateral bed rails were installed for two residents, and it also failed to show that alternative attempts were used before the rails were put in place. Resident 73 was admitted with bipolar disorder, Alzheimer’s disease, and Parkinson’s disease, and the MDS indicated impaired cognition and need for assistance with multiple ADLs. The admission order included a low bed with bilateral quarter rails and padded siderails for support, safety, mobility, repositioning, and ADLs, and the resident was observed in bed with bilateral side rails up. For Resident 73, staff interviews and record review showed the consent was incomplete because it did not include the padded bilateral quarter rails and was not verified by a second licensed nurse after being obtained by telephone. The IDT assessment did not indicate that bilateral rails were in use for support and safety, and it did not document alternative attempts before the rails were installed. The ADON stated that alternative attempts were not implemented prior to installing the bilateral rails because they were not documented in the side rail assessment or IDT note. Resident 99 was admitted with dementia, schizophrenia, and a history of falling, and the MDS indicated impaired cognition and need for maximal assistance with toileting, showering, lower body dressing, and footwear. The resident was observed in bed with bilateral side rails up. Staff stated that consent, alternative interventions, and an assessment were required before side rails were installed, but Resident 99’s consent form lacked the date and nurse’s signature, and staff noted that a second nurse signature was needed to verify accuracy. The side rail assessment showed visual monitoring was used before installation, and maintenance staff stated he measured the bed rails but did not measure all zones because he was unsure of their locations.
Medication Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5%, with 3 errors out of 29 opportunities for an overall error rate of 10.34% affecting two of five residents observed during medication administration. During observation, LVN 4 administered ferrous sulfate to Resident 92 by mouth and to Resident 97 via g-tube using a strength of 220 mg/5 ml, even though the physician’s orders for both residents specified ferrous sulfate 5 mg/20 ml. LVN 4 also administered one tablet of multivitamins with minerals to Resident 97, although the order called for multivitamins without minerals. Resident 92’s record showed diagnoses including dementia, and his history and physical indicated he did not have the capacity to understand and make decisions. Resident 97’s record showed diagnoses including cerebral infarction, and his history and physical did not indicate whether he had the capacity to understand and make decisions. During interview, LVN 4 stated he gave the wrong dose of ferrous sulfate to both residents, failed to verify that the formulation on hand matched the physician’s order, and should have contacted the physician to clarify the order. He also stated he administered the incorrect multivitamin formulation to Resident 97 and should have called the physician before giving the medication.
Food Storage and Sanitation Deficiencies
Penalty
Summary
Food safety, sanitary food storage, and food preparation practices were not maintained in the kitchen and storage areas. During observation with the Dietary Services Supervisor (DSS), two open corn tortilla packages were found in Refrigerator 2 on the top shelf, including one package with an open date of 2/7/2026 stored in its original plastic packaging and open to air, and another open package stored in plastic wrap with no open date. In the dry storage room, one dented pineapple can was stored on the same shelf as non-dented cans, and one open package of dried tri-colored pasta was stored in its original packaging and open to air. The DSS stated open refrigerated food should be labeled with an open date and stored in a covered container, and that loose food items should be placed in containers or bins that are dated, labeled, and covered. Additional observations showed a black trash bin with a broken lid that did not close and a brown trash bin with no lid in the handwashing area, with the DSS stating uncovered trash cans are not sanitary because they attract pests. Three cutting boards with visible cut marks were observed, and the DSS stated cutting boards with visible cut marks and scratches should be replaced because harmful bacteria can grow in the grooves and cause cross contamination. Four wet pans were stacked on top of each other, and the DSS stated pots and pans should be completely air-dried before stacking. Facility policies reviewed also indicated opened refrigerated corn tortillas should be dated, opened dry goods should be stored in tight-fitting lids or resealable bags, dented cans should be stored separately, trash bins should be covered at all times, cutting boards should be in good condition, and dishes and utensils should be air dried before storage.
Failure to Follow Linen Handling and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection control measures when CNA 2 handled Resident 186's clothing after it fell onto the hallway floor. Resident 186 was admitted with dementia, seizure disorder, DM, and paranoid schizophrenia, and the H&P stated the resident had no capacity to understand and make decisions. During observation, CNA 2 dropped a light brown hoodie on the hallway floor near Resident 182's room, picked it up, and later placed it in Resident 182's closet next to clean clothes. During interview, CNA 2 stated the hoodie became contaminated when it hit the floor and acknowledged it should have been placed in the dirty linen hamper or returned to laundry for rewashing instead of being hung with clean clothing. The Infection Preventionist Nurse stated CNA 2 should have taken the contaminated clothing to the laundry room right after picking it up from the floor rather than placing it in the closet with clean clothes. The DON stated staff should be mindful of surrounding and infection prevention measures to protect themselves and vulnerable residents from spreading infection. The facility policies for Standard Precautions, Infection Prevention and Control Program, and Laundry and Bedding stated that linen must be handled to prevent contamination, clean linen must be stored separately from soiled linen, and contaminated personal clothing should be immediately laundered before leaving the work area. The facility also failed to follow Enhanced Barrier Precautions for Resident 175. Resident 175 had diagnoses including diabetes, seizures, and dysphagia, was dependent in ADLs, and was on EBP for high-risk infections associated with feeding tubes. During observation, an EBP sign was posted in the room, gloves and gowns were available, and CNA 1 was changing used bed linens without wearing a gown or gloves. CNA 1 stated she saw the EBP sign but forgot to wear PPE and acknowledged she should have worn gloves and a gown while changing dirty linens. LVN 6 stated staff should wear a gown and gloves for high-contact care activities, including changing dirty bed linens, and the DON stated staff did not follow the EBP policy while providing care for Resident 175.
Incomplete Informed Consent for Padded Side Rails
Penalty
Summary
The facility failed to obtain a complete written informed consent before using padded bilateral upper side rails for Resident 196. The resident was admitted with diagnoses including tracheostomy, gastrostomy, and diabetes, and the MDS dated 1/29/2026 indicated the resident was severely cognitively impaired. A physician order dated 1/31/2026 directed the facility to obtain informed consent from the resident representative after explanation of the risks and benefits for the use of padded bilateral upper side rails when the resident was in bed, and the care plan also identified low bed with padded bilateral upper half side rails up and locked when in bed for safety and positioning. The informed consent form for low bed with bilateral upper half side rails was undated and indicated documentation was to be completed before treatment was initiated for use of a restraint, but it did not show a signature from the prescribing physician, resident representative, or nurse verifying the consent. During observation on 2/9/2026, the resident's bilateral upper side rails were padded and locked in position. The LVN stated she entered the physician order into the system and forgot to ensure the informed consent form was completed. The DON reviewed the facility's Bed Safety and Bed Rails policy and stated padded side rails are a safety device and require informed consent prior to use, and that staff did not follow the facility's policy. The facility's Informed Consent policy stated the prescribing physician, resident or resident representative, and verifying nurse must sign the form to ensure completeness.
Advance Directive and POLST Not Completed
Penalty
Summary
The facility failed to ensure Advance Directives were discussed and written information was provided to residents and/or responsible parties, and failed to ensure a completed POLST was in place for one sampled resident. Resident 18 was admitted and re-admitted with diagnoses including senile degeneration of the brain, bipolar disorder, dementia, and encephalopathy. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed the resident required dependent assistance from two or more staff for eating, hygiene, shower/bath, dressing, bed mobility, and transfer. During record review and interview, Resident 18’s POLST showed a DNR order, but Section D for AD was left blank and was not completed. The RNS stated the POLST was not completed because there was missing information and that if the POLST was not completed, the resident would be treated as full code and all life sustaining measures would be done during an emergency per policy. The RNS also stated the resident would be treated against his/her wish. The SSA reviewed the POLST with the resident’s RP by telephone and documented that the RP agreed to remain DNR, selective treatment, no artificial means of nutrition including feeding tubes, and no advance directive. However, the SSA stated she did not provide written materials regarding AD, did not complete and update the POLST, and should have had a witness while obtaining verbal consent by telephone. The DON stated AD and POLST should be available for all residents and that staff should have ensured completion of the POLST and provided written information regarding AD. Facility policy stated residents or representatives are to be provided written information concerning the right to refuse or accept treatment and to formulate an advance directive.
Failure to Notify Physician of Tube Feeding Refusal
Penalty
Summary
The facility failed to ensure nursing staff notified the physician in a timely manner when a resident refused tube feeding for the day. Resident 122 was admitted and readmitted to the facility with diagnoses including quadriplegia, acute respiratory failure, and gastrostomy. The resident's MDS indicated intact cognitive skills for daily decision-making and dependence for mobility and self-care, including eating, hygiene, and dressing. The resident's orders directed Jevity 1.5 tube feeding at 60 mL/hr for 20 hours via pump to provide 1200 mL and 1800 kcal per day. On observation, the tube feeding pump was connected to the resident but turned off, with about 1400 mL of formula left in the bottle. A later observation showed the same condition, with the pump still off and the formula still remaining. During interview, an LVN stated the tube feeding had been running earlier in the day, but the resident did not want it to continue, so the LVN turned the pump off and flushed the tube. The LVN stated the primary physician should have been notified when the resident refused tube feeding, but the physician was not notified. The RD stated nursing staff should report refusal of tube feeding to the physician and/or RD and document that they were made aware. The DON stated nursing staff should document the refusal, call the primary physician, and inform the resident about the risks and benefits of refusal. The facility policy stated the healthcare practitioner must be notified of refusal of treatment in a time frame determined by the resident's condition and potential serious consequences of the request.
MDS Did Not Accurately Capture Bed Rail Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected resident status for two sampled residents, Resident 73 and Resident 99. Resident 73 was admitted with diagnoses of bipolar disorder, Alzheimer's disease, and Parkinson's disease, and the MDS dated 1/26/2026 indicated impaired cognition and assistance needs for bathing, toileting, dressing, footwear, and personal hygiene. During observation, Resident 73 was found lying in bed with padded bilateral side rails up, and the order summary showed a physician's order for a low bed with bilateral quarter rails as an enabler for bed mobility, repositioning, and other ADLs, with padded siderails to decrease potential injury. The MDS Nurse stated the assessment was not completed accurately and that the section on restraints and alarms incorrectly addressed whether Resident 73 used bed rails and padded side rails, noting the bilateral side rail was not captured because it is not considered a restraint. Resident 99 was admitted with diagnoses of dementia, schizophrenia, and history of falling, and the MDS indicated impaired cognition and maximal assistance needs for toileting, showering, lower body dressing, and putting on/taking off footwear. During observation, Resident 99 was lying in bed with bilateral siderails up, and the order summary also showed a physician's order for a low bed with bilateral quarter rails as an enabler for bed mobility, repositioning, and other ADLs, not considered a restraint. The ADON stated that the MDS nurse should have captured the use of bed rails in Resident 99's annual assessment and Resident 73's quarterly assessment, and that accurate completion of the assessment was important to create a care plan that meets both residents' needs.
Failure to Follow Fall Care Plan Interventions
Penalty
Summary
The facility failed to implement the nursing interventions according to the care plan for Resident 99. Resident 99 was admitted with diagnoses of dementia, schizophrenia, and a history of falling. The MDS dated [DATE] indicated that the resident had impaired cognition and required maximal assistance with toileting, showering, lower body dressing, and putting on/taking off footwear. During an observation on 02/09/2026 at 9:49 a.m., Resident 99 was lying in bed facing the door with bilateral siderails up and the call light within reach, but there were no floor mats or bed alarm in the room. The care plan initiated on 5/6/2021 included a Falling Star Program with interventions for floor mats, bed/chair alarm, and IDT conferences for falls. During an interview and record review on 2/11/2026 at 12:45 p.m., LVN 4 stated that the care plan was not updated to reflect the resident's current needs, the facility did not follow the care plan regarding the floor mat and bed alarm, and Resident 99 had never had a bed alarm. The facility policy stated that assessments are ongoing and care plans are revised as information about residents and their condition changes.
Failure to Follow Pain Care Plan Interventions
Penalty
Summary
The facility failed to follow Resident 20’s care plan and implement nonpharmacological interventions for pain. Resident 20 was admitted with diagnoses including HTN, schizophrenia, and low back pain. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated moderate cognitive impairment, dependence on staff for toileting and bathing, and maximal assistance needed for dressing and personal hygiene. During interview, Resident 20 stated pain medications sometimes helped with recurrent right shoulder pain, said he had never been offered anything besides pain medications, and stated a hot pack might help and that he was interested in trying alternative interventions. A concurrent review of the care plan titled Actual Pain: Right Shoulder Pain showed nonpharmacological interventions including hot pack, cold pack, massage, and distraction. LVN 2 stated a hot pack had never been offered because the resident usually had a lidocaine patch on the right shoulder, and acknowledged the care plan interventions should have been followed to better manage the resident’s pain. RN 1 reviewed the nurses’ progress notes and stated there was no documentation of nonpharmacological interventions implemented to address the resident’s pain. The facility policy on comprehensive person-centered care plans stated the care plan describes services to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.
Inaccurate pain assessment when behavioral signs were not used
Penalty
Summary
The facility failed to ensure nursing staff used behavioral signs of pain to assess pain for one resident with a history of hypertension, schizophrenia, and low back pain. The resident's record showed he was admitted on 11/15/2021, had no capacity to understand and make decisions per the H&P, and had moderate cognitive impairment on the MDS. He was dependent on staff for toileting and bathing and required maximal assistance with dressing and personal hygiene. During an interview, the resident stated he had recurrent right shoulder pain and rated it as 6 out of 10, and said the pain remained unrelieved after receiving pain medication. In a concurrent interview and record review, an LVN stated that when he assessed the resident, the resident yelled that he was in pain but refused to give a numeric pain score, yet the LVN documented the pain level as 0 out of 10. The LVN stated this documentation was inaccurate and that he should have assessed behavioral signs of pain such as facial grimacing, moaning, and irritability. The DON stated licensed nurses are expected to assess pain each shift and as needed, and when residents cannot verbalize a numeric pain level, nurses should assess behavioral signs of pain. The facility policy also directed staff to observe residents for physiologic and behavioral signs of pain and document the resident's reported pain level with adequate detail.
Failure to Provide Ordered RNA Services
Penalty
Summary
The facility failed to ensure one of three sampled residents, Resident 15, received restorative nursing assistant (RNA) services that were ordered to maintain range of motion and mobility. Resident 15 was admitted and readmitted to the facility with diagnoses including schizophrenia, dementia, and diabetes mellitus. The record also showed that Resident 15 had intact cognitive skills on the MDS, but was dependent for self-care activities such as eating, hygiene, and dressing, and dependent for mobility activities including sitting to lying and transfers. Resident 15 had physician orders for RNA to perform passive range of motion (PROM) to both lower extremities every day five times a week or as tolerated, PROM to both upper extremities every day five times a week or as tolerated, and soft hand rolls to both hands up to four hours every day five times a week or as tolerated. The December 2025 Documentation Survey Report showed the RNA services were documented as completed five days a week, but there were entries of NA for PROM to both lower extremities on 12/30/2025 and 12/31/2025, PROM to both upper extremities on 12/30/2025 and 12/31/2025, and soft hand rolls on 12/25/2025, 12/30/2025, and 12/31/2025. During observation, Resident 15 was resting on his left side and stated he could not use his hands and was not able to use his wheelchair as before. He also stated he was not getting physical therapy and was not sure about getting RNA services. RNA staff stated that if the services were not documented, they were not provided, and the DON stated residents in the RNA program should receive services as ordered and that if it was not documented, it means the services were not provided as ordered.
Tube Feeding Pump Not Functioning for Resident With Gastrostomy
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube received ordered tube feeding when the feeding pump was not functioning as intended for more than three hours. Resident 5 was admitted with diagnoses including acute respiratory failure, gastrostomy, and persistent vegetative state, and was dependent for mobility and self-care. The resident’s MDS indicated the resident was rarely or never understood and unable to communicate needs. Resident 5 had an order for Jevity 1.5 at 60 mL/hr for 20 hours via pump, with the pump to be turned on at 12:00 p.m. and off at 8:00 a.m. During an observation, the tube feeding tubing was connected to the resident but the pump was not on. Later the same day, the pump was observed on, but the feeding was not moving into the resident and the formula bottle remained full at 1500 mL. The LVN stated the pump had been turned on at 12:00 p.m. and did not know why the feeding was not infusing until troubleshooting was started. The RD stated that if the feeding was started at 12:00 p.m. and the bottle was still full at 3:38 p.m., the resident did not receive any tube feeding. The DON stated this meant over three hours without tube feeding and confirmed the bottle should have reflected intake by that time. The DON also stated staff were expected to assess the resident, complete a change-in-condition assessment, notify the physician, and start the tube feeding right away. The facility policy stated enteral nutrition should be provided as ordered and that staff responsible for administering enteral nutrition must be trained, qualified, and competent.
Improper Storage of Unopened Insulin Pens
Penalty
Summary
Two unopened Humalog insulin pens for Residents 160 and 207 were found stored in Station 3 Medication Cart A at room temperature instead of in the refrigerator as required by the manufacturer’s labeling. During the concurrent observation and interview, the LVN stated that the insulin pens for Residents 160 and 270 were being kept at room temperature and were not labeled with an open date. The LVN also stated that unopened insulin should be refrigerated because once it is stored at room temperature it is only good for 28 days, and that without an open date staff would not be able to know accurately when it expires. The medication storage issue was identified during observation, interview, and record review of the medication cart. The facility policy titled Storage of Medications stated that medications and biologicals are to be stored safely, securely, and properly according to manufacturer recommendations, and that medications requiring refrigeration are to be kept in a refrigerator with a thermometer for temperature monitoring.
Missed Weekly Hospice RN Visit
Penalty
Summary
The facility failed to ensure that Resident 18, who was under hospice care, was visited by hospice licensed nurses weekly as required by the hospice care agreement. Resident 18 was admitted with diagnoses including senile degeneration of the brain, bipolar disorder, dementia, and encephalopathy. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed the resident was dependent on staff and required assistance from two or more staff for eating, hygiene, bathing, dressing, bed mobility, and transfer. During review of the resident’s February 2026 patient calendar and hospice communication records, there was no initial or documentation for the hospice RN visit on 2/10/2026. The RNS stated the hospice RN should have signed in, documented the assessment in a communication note, and visited weekly every Tuesday per the hospice agreement, but facility staff did not follow up with hospice staff regarding the missing visit. The DON also stated staff should have followed up to ensure the weekly hospice licensed nurse visit occurred and that the resident received the hospice care agreed upon. The hospice certification of terminal illness indicated skilled nursing service from an RN or licensed nurse once a week for 13 weeks and aide service twice a week for 13 weeks, and the care plan included referral to hospice services as ordered.
Resident-to-Resident Physical Abuse Involving Unlocked Closet Access
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident pushed a roommate, causing the roommate to fall to the floor and sustain a traumatic skin tear to the right eyebrow that required emergency department treatment. The injured resident had diagnoses including dementia, depression, and Alzheimer’s disease, and the MDS indicated severely impaired cognition with partial assistance needed for several activities of daily living. The resident who pushed the roommate also had dementia, anxiety, restlessness, and agitation, and had a care plan addressing ineffective coping with episodes of anger or hostility toward other residents. On the morning of the incident, the injured resident was observed walking in the hallway and cleaning handrails with paper towels. The other resident was observed in bed with side rails up and the call light within reach, while the closet door in that room was slightly ajar. Later, the injured resident was found on the floor bleeding from a cut on the right side of the forehead, and staff applied pressure before transferring the resident to the emergency department. The emergency documentation noted a head laceration and diagnosis of assault and facial laceration, and the laceration was closed with dermabond. The resident who pushed the roommate stated that the roommate had been in her closet, looking through belongings and speaking Spanish, which she did not understand. She stated she pushed the roommate away from the closet twice, and the second push caused the roommate to fall. Staff interviews and record review showed the room closets were not locked because the locks did not work, although staff stated the closets were supposed to remain locked at all times. Staff also stated the injured resident frequently wandered into other residents’ rooms and tried to clean or fix things, but this behavior was not monitored and was not included in a care plan. Facility staff, including nursing and social work staff, stated the altercation could have been avoided if the closet had been locked and if the residents had been separated when the earlier argument began over water on the floor.
Failure to Use Required Two-Person Assist and Prevent Bed-Related Injury During Repositioning
Penalty
Summary
The deficiency involves a failure to ensure the environment was free from accident hazards and that adequate supervision and assistance were provided during resident repositioning. A Licensed Vocational Nurse (LVN 1) repositioned a resident who, per the Minimum Data Set (MDS), was dependent on staff and required the assistance of two or more helpers to roll from side to side. Despite knowing the resident was a two-person assist, LVN 1 proceeded to reposition the resident alone because other staff were busy. The facility’s policy on positioning and moving residents required staff to assess the resident’s physical abilities, mobility limitations, strength, awareness, and ability to follow directions, and to use maximum precautions and obtain assistance as needed, but this was not followed. The resident involved had severe cognitive impairment due to dementia and Alzheimer’s disease and was documented as dependent on staff for rolling left to right, with functional limitations in range of motion in both upper and lower extremities. On the evening of the incident, CNAs caring for the resident, who also stated the resident required a two-person assist, noticed the resident’s right knee was bending abnormally and informed LVN 1. During LVN 1’s rounds, she found the resident at the edge of the right side of the bed with the right foot hitting the bed’s footboard. To prevent a fall, LVN 1 decided to reposition the resident without waiting for assistance, using a draw sheet to pull the resident up while both legs were straight and the right leg crossed over the left. As LVN 1 turned the resident toward the left side of the bed, the resident moved her legs and the right knee struck an exposed portion of the bed frame at the bottom of the bed where the mattress did not fully cover the frame. LVN 1 observed the resident grimacing and moaning, with redness, swelling, and tenderness of the right knee. Subsequent assessment and imaging showed an acute right distal femur fracture. The resident was transferred to a general acute care hospital, where the fracture, associated swelling, deformity of the distal thigh, and need for immobilization, pain control, and monitoring for complications were documented. An orthopedic consultation later noted the injury was likely related to malunion and that surgery was not recommended due to the resident’s dementia and non-ambulatory status.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to immediately report an allegation of physical abuse involving a resident with moderate cognitive impairment and multiple medical diagnoses, including hypertension and type 2 diabetes. The resident disclosed to an LVN that an unknown individual had pulled her hair in the hallway a few days prior, but the LVN did not report the allegation to the RN supervisor or the Administrator as required by facility policy. The RN working alongside the LVN was not informed of the incident, and the Administrator confirmed that the facility's abuse policy mandates immediate reporting to supervisors and notification to the State Agency within two hours of awareness. The failure to report the allegation promptly resulted in a delay in initiating an investigation and notifying the appropriate authorities, including the State Survey Agency and law enforcement. The facility's policy and procedure, as well as statements from the RN and Administrator, emphasized the importance of immediate reporting to ensure resident safety and compliance with regulatory requirements. The incident was not reported in accordance with these protocols, constituting a deficiency in the facility's handling of abuse allegations.
Delayed Physician Notification and Transfer Following Acute Femoral Fracture
Penalty
Summary
The facility failed to provide timely medical intervention and transfer for a resident who experienced a significant change in condition related to unmanaged pain and a delayed response to an acute right femoral fracture. Staff did not promptly notify the resident's physician after receiving a stat x-ray result indicating an acute proximal femoral fracture with soft tissue swelling. The x-ray result was received at 1:22 a.m., but the physician was not notified until 8:35 a.m., resulting in a delay of over seven hours before appropriate action was taken. During this period, the resident continued to experience severe pain and swelling, as documented by multiple pain assessments and nursing progress notes. The resident had a complex medical history, including chronic respiratory failure, ventilator dependence, osteoporosis with pathological fractures, quadriplegia, and contractures. On the day of the incident, staff observed the resident with facial grimacing, an unstable right hip, and increased pain during repositioning. Despite these findings and the subsequent x-ray confirming a fracture, the facility did not follow its own care plan and policy requirements for prompt physician notification and intervention. Pain management was inconsistent, with the resident receiving Tylenol and later Norco, but continued to exhibit signs of severe pain, including hyperventilation, moaning, and rigidity. The facility also failed to implement its policy on changes in a resident's condition, which requires immediate notification of the attending physician and resident representative upon significant changes. The delay in notification and transfer resulted in the resident experiencing unmanaged pain and increased swelling for approximately 10 hours before being transferred to a general acute care hospital. The resident ultimately underwent a surgical procedure involving removal of the femoral head and neck with hip disarticulation.
Failure to Maintain Low Bed Position for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident assessed as high risk for falls had their bed placed in the lowest position, as required by the resident's care plan under the Falling Star Program. The resident, who had diagnoses including generalized weakness, cognitive impairment, poor balance, decreased strength, and a history of falls, was observed asleep in bed positioned close to the edge of the mattress. Measurement of the bed height revealed it was set at 16 inches from the floor, rather than the lowest possible setting of 14 inches, as specified in the care plan. In contrast, the resident's roommate's bed was observed to be almost at floor level. Interviews with facility staff, including the Registered Nurse Supervisor and the Director of Nursing Services, confirmed that interventions such as low bed positioning are discussed and expected to be implemented according to residents' care plans to reduce fall risk. The facility's policies require that care plan interventions be implemented based on ongoing assessments and that specific fall prevention measures be carried out for residents at risk. Despite these policies and the resident's documented needs, the intervention to keep the bed in the lowest position was not followed at the time of observation.
Failure to Initiate Immediate CPR for Full Code Resident
Penalty
Summary
The facility failed to provide immediate Cardiopulmonary Resuscitation (CPR) to a resident with a Full Code status who was in distress, significantly reducing the resident's chances of survival. The incident involved a resident who was admitted with multiple diagnoses, including Type II Diabetes, Sepsis, and Urinary Tract Infection, and had a care plan indicating CPR should be performed in case of a life-threatening emergency. On the day of the incident, the resident was found unresponsive with no palpable pulse, yet CPR was not initiated immediately by the attending Registered Nurse (RN). The RN failed to announce a Code Blue and did not provide resuscitation or basic life support immediately, despite the resident's unresponsiveness and lack of a detectable pulse. The RN relied on an oximeter reading, which still indicated a pulse, instead of manually checking for a pulse and initiating CPR as per the facility's policy and procedure. This delay in initiating CPR was contrary to the facility's policy, which required immediate CPR initiation when a resident with Full Code status is found unresponsive and not breathing normally. The facility's policy, aligned with the American Heart Association guidelines, mandates that CPR should be started immediately upon recognizing cardiac arrest symptoms, such as the absence of a palpable pulse. The RN's lack of adherence to these guidelines and the facility's procedures resulted in a delay in life-saving measures, as the paramedics had to initiate CPR upon their arrival. This deficiency highlights a critical lapse in the facility's emergency response protocol, particularly in the timely initiation of CPR for residents with Full Code status.
Removal Plan
- The Administrator and the Director of Nursing notified the facility Medical Director of the findings outlined in the IJ removal plan and developed an IJ removal plan.
- American Heart Association Instructors provided in-services to nurses on the facility's CPR policy and procedure. The training covered assessment and activation for CPR, code for cardiac/respiratory arrest-Code Blue, and CPR procedures.
- All nursing including part time and overnight shift who was unable to attend the Inservice must be given an in-service prior to returning to work.
- The DON and Registered Nurse supervisor reviewed residents who required CPR and identified one resident aside from Resident 44 with an incident of code blue with not the same deficient practice.
- The AHA instructors will repeat the in-services to nursing staff, regarding CPR policy and procedure, every month for 3 months to ensure compliance.
- The DON and/or designee will review residents who have a change in condition weekly and monthly thereafter, to ensure that any resident requiring CPR has received the CPR timely, and continually until the paramedics arrive or there are obvious signs of life.
- The DON and/or designee will review residents who have change in condition weekly and monthly thereafter, to ensure that any resident required.
Failure to Manage Severe Weight Loss in Resident with Gastrostomy Tube
Penalty
Summary
The facility failed to ensure adequate nutritional management for a resident receiving gastrostomy tube feeding, resulting in severe weight loss. The resident, who had a history of muscle wasting, non-Hodgkin lymphoma, and multiple pressure ulcers, experienced a significant weight loss of 25.8 pounds, equating to 21.6% of their body weight over a two-month period. Despite the resident's care plan indicating a goal to prevent weight loss exceeding 5% per month, the facility did not conduct a change of condition assessment or monitor the resident's weight and nutritional status closely. The licensed nurses did not notify the resident's physician or responsible party of the significant weight loss, nor did they inform the registered dietician in a timely manner to evaluate the resident's nutritional needs. The interdisciplinary team failed to meet to develop interventions to prevent further weight loss, and the resident's care plan was not updated with measurable goals to address the weight loss. Additionally, the facility did not document the resident's weight changes accurately or consistently, leading to a lack of timely interventions. The resident's weight loss was not addressed adequately, and the facility's staff did not follow the established protocols for monitoring and managing significant weight changes. The lack of communication and documentation among the care team contributed to the resident's continued weight loss, placing them at risk for malnutrition and dehydration. The facility's failure to implement appropriate interventions and notify relevant parties resulted in a deficiency that posed a risk to the resident's health.
Removal Plan
- A change of condition assessment, SBAR for severe weight loss was completed, which included vital signs, pain, laboratory results reviewed and obtained new physician orders for adding Liquacel and to increase GT feeding to 55cc/hr.
- The assistant director of nursing conducted another assessment, indicating the Resident 188 remained at his baseline condition with normal vital signs, and without any sign of distress.
- The IDT members, including the RD, conducted an IDT care plan meeting. During the meeting, the IDT members addressed Resident 188's overall condition with severe weight loss. The physician instructed to start weekly weight for four weeks and repeat the comprehensive metabolic panel.
- RNA 1 will receive a performance correction notice, and a one-on-one in-service by the DON regarding weight documentation, emphasizing the importance of recording the weight on the same day it was measured.
- The weights management in-service was initiated until all licensed nurses, including part-time and night shift will be completed. Any licensed nurse unable to attend the in-service due to part time status, emergency or leave of absence has been removed from the schedule and must be given an in-service prior to returning to work.
- The DON and ADON initiated review of all residents' weight records for the past 30 days to ensure that all significant or severe weight changes had proper assessments, RD recommendations, MD notifications, and updated plan of care.
- The DON and the ADON will conduct monthly in-services to licensed nurses regarding weight management for 3-months, covering the following details: Conducting a change of condition assessment for significant or severe weight change.
- The DON and/or designee will repeat a monthly in-service for three months to RNA responsible for weights documentation, to ensure all weights are recorded on the same day it is measured.
- The DON created a weight management monitoring log, including significant or severe weight loss.
- The DON/ADON will meet with the RNA weekly for four weeks, then monthly for three months to ensure timely weight documentation.
- The DON/ADON will participate in weekly weight management meeting and document the findings with corrective actions in the monitoring log.
- The DON/ADON will monitor weight variance through weekly weight meeting to ensure all residents with weight variance (significant or severe) will be addressed. The DON will discuss weight management related findings during the monthly QA meeting for three months to ensure ongoing compliance with the state and federal regulations.
Failure to Follow Sanitation and Infection Control Policy
Penalty
Summary
The facility failed to adhere to its own sanitation and infection control policy, which mandates working under sanitary conditions at all times. During an observation and interview, a Regional Registered Dietitian (RRD) was seen handling a food thermometer without performing hand hygiene or wearing gloves. The RRD used an alcohol swab to clean the thermometer before inserting it into pureed broccoli and repeated the process without washing hands or using gloves. The RRD acknowledged that hand hygiene is essential to prevent cross-contamination but justified the lack of gloves by stating that the cook had already taken the food's temperature. The facility's Policies and Procedures require hand washing before and after handling food and the use of disposable gloves when handling ready-to-eat foods, which was not followed in this instance.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage and labeling practices, which could lead to foodborne illnesses among residents. Observations revealed that frozen meats and vegetables were stored together without proper separation, and many items, including pie crusts, pepperoni, and various vegetables, were undated. Additionally, opened sausages and croissants were stored together in the produce fridge, and several items, such as thickened milkshakes and cottage cheese, lacked proper labeling and dating. Molded and expired bread and cottage cheese were also found, indicating a lack of adherence to food safety protocols. The facility also failed to maintain proper sanitation practices in the dishwashing process. Chlorine test strips, necessary for ensuring the dishwasher's effectiveness, were missing, and staff were unable to verify the chlorine levels before running the dishwasher. This oversight could result in inadequate sanitization of dishes, potentially exposing residents to harmful pathogens. Furthermore, the facility lacked a scale to ensure proper portion sizes, which could affect the nutritional intake of residents. Interviews with staff, including dietary aides, the registered dietitian, and the dietary manager, confirmed these deficiencies. Staff acknowledged the improper storage and labeling of food items and the absence of necessary equipment, such as chlorine test strips and a food scale. The facility's policies and procedures for food storage and dishwashing were not followed, contributing to the potential risk of foodborne illness among the residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring that two out of three blue dumpsters were completely covered. This was observed during a visit to the garbage area located outside the facility near the kitchen. The Dietary Manager confirmed that the trash bin lids were not completely closed, which could attract pests. Additionally, three black trash bags were found on the floor between the dumpsters. The Maintenance Supervisor also observed one of the dumpsters open, with a black trash bag, flattened cardboard boxes, and soiled diapers in the walkway next to the dumpsters. The facility's Policies and Procedures, titled Waste Control and Disposal, require that trash bins be covered at all times and that outside garbage bins be kept closed with the surrounding area kept clean. The policy also mandates timely disposal of garbage to prevent buildup and requires that all cardboard boxes be broken down and disposed of promptly. The failure to adhere to these procedures had the potential to attract flies, insects, and other animals, posing a risk of cross-contamination for the majority of the facility's residents who receive food from the kitchen.
Failure to Track and Educate on COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer, educate, and track COVID-19 vaccinations for staff according to its policy, potentially placing all residents at risk for coronavirus infection. During an interview with the Infection Preventionist Nurse (IPN), it was revealed that the facility did not maintain a tracking log or retain records of vaccination education, proof of vaccination, or declinations for staff. The Director of Nursing (DON) acknowledged the importance of educating and documenting staff vaccinations to protect both residents and staff. A review of the facility's COVID-19 policy indicated that the facility was required to educate residents, responsible parties, and staff about the benefits of vaccination, offer vaccinations based on health department recommendations, and keep copies of vaccination proof. Additionally, if an employee chose not to be vaccinated, they were required to provide a written declination.
Failure to Provide Effective Communications Training for Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory Effective Communications training for its direct care staff, which includes 18 Registered Nurses (RNs), 50 Licensed Vocational Nurses (LVNs), and 20 Respiratory Therapists (RTs). This deficiency was identified during interviews and record reviews conducted by surveyors. The Director of Staff Development (DSD) admitted to being unaware of the requirement for this training, and as a result, it was not provided in 2024. The facility's policy and procedure, revised in August 2022, clearly states that all staff must participate in regular in-service education, including Effective Communications, to ensure they can interact in a manner that enhances residents' quality of life and care. The Director of Nursing (DON) emphasized the importance of effective communication, particularly for non-English speaking residents and those with specific needs such as dementia, traumatic brain injury, or stroke. These residents rely on alternative communication methods, and without proper training, staff may not be able to meet their needs, potentially affecting the quality of care provided. The facility's policy requires that training be completed before staff provide services to residents, annually, and as necessary based on the facility's assessment, but this was not adhered to, leading to the deficiency.
Failure to Provide Mandatory QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to its direct care staff, including 18 Registered Nurses (RNs), 50 Licensed Vocational Nurses (LVNs), and 20 Respiratory Therapists (RTs), as required by the facility's policy and procedure. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), who admitted to being unaware that QAPI training was mandatory for direct care staff and consequently did not provide the training in 2024. The facility's policy, revised in August 2022, clearly states that all staff must participate in regular in-service education, including QAPI training, to ensure they can enhance residents' quality of life and care. The Director of Nursing (DON) emphasized the importance of QAPI as an ongoing process to address issues, improve communication among staff, and ensure proper resident care. The lack of training could lead to staff being unaware of updated facility procedures, proper communication protocols, or how to assist residents effectively. The facility's policy indicates that training requirements must be met before staff provide services to residents, annually, and as necessary based on the facility's assessment. The failure to conduct this training had the potential to result in poor communication among staff, lack of awareness of facility updates, lack of collaborative work, and compromised resident care.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to involve Resident 188 and his responsible party, FM 1, in the development and implementation of a care plan addressing significant weight loss. Resident 188 was admitted with multiple health issues, including a gastrostomy tube, muscle wasting, non-Hodgkin lymphoma, a tracheostomy tube, and multiple pressure ulcers. Despite a documented weight loss of 25.8 lbs. (21.7%) over two months, there was no evidence that FM 1 was informed or involved in creating a care plan to address this issue. The Assistant Director of Nursing (ADON) confirmed the absence of a care plan for severe weight loss and acknowledged the importance of involving the resident and responsible party in the care planning process. Resident 19, who was cognitively intact and had functional range of motion limitations, was not involved in the care planning process when Restorative Nursing Aide (RNA) services for range of motion exercises to both legs were discontinued. The RNA services were discontinued due to Resident 19's refusal, which was not adequately discussed with him or documented. The ADON and RNA 2 confirmed that the plan of care should have been discussed with Resident 19, and an interdisciplinary team (IDT) meeting should have been conducted to explore alternative options and reasons for refusal. The facility's policy and procedure on resident rights emphasize the importance of involving residents in their care planning and treatment. However, in both cases, the facility failed to ensure that the residents and their responsible parties were informed and involved in their care plans, leading to deficiencies in the care provided to Residents 188 and 19.
Failure to Update Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that the medical records of four residents were updated to reflect their advance directives, which are crucial for honoring their healthcare wishes. Resident 37, who was diagnosed with dementia and other conditions, did not have a confirmed advance directive due to the unresponsiveness of the assigned public guardian. Despite multiple attempts by the Social Service Director (SSD) to contact the guardian, there was no response, leaving the resident's healthcare preferences unconfirmed. Resident 343, also diagnosed with dementia and other mental health conditions, lacked a signed advance directive upon readmission. The SSD noted that the public guardian had not signed the necessary documents, and the resident's advance directive remained incomplete. Similarly, Resident 55, who had severe cognitive impairments, did not have a confirmed advance directive due to difficulties in contacting a family member who frequently changed contact information. The resident's care was under the facility's interdisciplinary bioethics committee, but the advance directive was still pending approval from a public guardian. Resident 46, with severe cognitive impairments and multiple diagnoses, had an outdated advance directive from 2022 that was not followed up on. The resident was marked as full code by default, awaiting a response from a representative. The facility's policies and procedures require that advance directives be honored and reviewed annually, but these were not adhered to, resulting in the deficiency. The lack of updated advance directives for these residents had the potential to cause conflicts with their healthcare wishes.
Failure to Notify Physician and Family of Significant Changes in Residents' Conditions
Penalty
Summary
The facility failed to notify the physician and responsible party of a significant change in condition for Resident 188, who experienced a severe weight loss of 21.6% over 60 days. Despite the facility's policy requiring notification of significant weight changes, the physician and family member were not informed in a timely manner. The resident's weight dropped from 119 lbs. to 93.2 lbs., and the care plan goals were not met as the weight loss exceeded the 5% per month threshold. Interviews with staff revealed a lack of understanding and adherence to the facility's policy on change of condition notifications. Additionally, the facility did not report a change of condition for Resident 19, who was at high risk for contracture development and had refused restorative nursing aide services for range of motion exercises. The refusal was not communicated to the physician, and no interdisciplinary team meeting was conducted to address the change in the resident's plan of care. The facility's policy required notification of the physician and the resident's representative when there was a significant change in the resident's condition, but this was not followed. The facility's policies on weight assessment and change in resident's condition were not adhered to, resulting in a lack of timely interventions and communication with the physician and family members. The failure to notify the physician and responsible parties of significant changes in residents' conditions could potentially delay necessary care and interventions, as noted in the interviews with the facility's staff and the physician.
Improper Use of Restraints in LTC Facility
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the use of physical restraints, as evidenced by the improper application of side rails and a lap tray for two residents. For Resident 24, the facility did not explore alternative measures to prevent falls before raising all four side rails, which were considered a restraint. Despite the resident's request for side rails, there was no documented consent indicating that the resident was informed of the risks and benefits. Additionally, the facility did not conduct a pre-restraining assessment to determine if the resident could lower the side rails independently, nor did they document any attempts to use less restrictive measures. The facility also failed to hold an interdisciplinary team (IDT) meeting to discuss the appropriateness of the restraint, and there was no evidence of staff monitoring the resident's condition or the effectiveness of the restraint. Resident 161 was placed in a Geri chair with a lap tray, which acted as a restraint since the resident was unable to remove it independently. The facility did not perform a pre-assessment to determine the necessity of the lap tray or assess whether the resident could remove it. There was no documentation of alternative measures being attempted before applying the lap tray, and no IDT meeting was held to evaluate the restraint's appropriateness. The resident was observed trying to stand but was blocked by the lap tray, indicating a lack of consideration for the resident's mobility needs. The facility's policy on the use of restraints requires a pre-restraining assessment, obtaining informed consent, and ongoing evaluation of the restraint's necessity. However, these procedures were not followed for either resident. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the failures, noting that staff did not recognize the side rails and lap tray as restraints and did not implement necessary safety measures. This oversight compromised the residents' dignity and safety, creating an unsafe environment and increasing the risk of injury.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASRR) assessments for two residents, which is crucial for determining the facility's ability to meet their special needs. Resident 16 was admitted with diagnoses including psychosis, schizoaffective disorder, and major depressive disorder. Despite these serious mental health conditions, the PASRR Level I screening inaccurately indicated that Resident 16 did not have a serious mental illness. The Assistant Director of Nursing (ADON) acknowledged that the hospital typically conducts the PASRR Level I screening and sends it to the facility, but if a Level II is required and not available, the facility would follow up. The ADON also stated that a new PASRR Level I screening would be conducted if there was a change in condition or if the initial screening was inaccurate. Similarly, Resident 55 was admitted with major depressive disorder, dementia, and psychosis, yet the PASRR Level I screening also incorrectly indicated no serious mental illness. The ADON confirmed the inaccuracies in the PASRR Level I documentation for both residents, emphasizing the importance of the PASRR process in ensuring residents' psychological and mental health needs are addressed. The facility's policy requires a new Level I PASRR to be submitted if there is any error or discrepancy in the previous screening, and designated staff are responsible for reviewing information from the PASRR Online System regularly.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for nine residents, leading to unmet needs and potential negative outcomes. Resident 19, who has quadriplegia and functional range of motion limitations, refused Restorative Nursing Aide services for passive range of motion exercises. Despite the resident's refusal, the facility did not create a care plan to address these refusals, which could lead to a decline in the resident's mobility and range of motion. The Minimum Data Set Coordinator confirmed the absence of a care plan for these refusals, emphasizing the importance of having goals and interventions in place to maintain the resident's current level of function. Resident 46, diagnosed with epilepsy and experiencing seizures, did not have an updated care plan to address actual seizures and the medications prescribed for them. The resident had multiple seizure episodes, yet the care plan had not been revised since 2022 to include interventions for these occurrences. Licensed Vocational Nurse 5 and the Assistant Director of Nursing acknowledged the need for a care plan that includes interventions for actual seizures and the medications being administered. The lack of an updated care plan could result in inadequate monitoring and management of the resident's condition. Residents 55, 21, and 188 experienced significant weight loss, but the facility failed to initiate care plans to address this issue. Resident 55 had a care plan for anticipated weight loss but not for actual weight loss, and the care plan had not been revised for a year. Resident 21's care plan did not include interventions for actual weight loss, and the Registered Dietitian was unsure if a specific care plan was needed. Resident 188 experienced severe weight loss, yet no care plan was created to address this change in condition. The Assistant Director of Nursing highlighted the importance of having a care plan to prevent further weight loss and ensure staff are aware of the necessary interventions. Additionally, Residents 40, 74, and 59 required specialized services as determined by their PASRR evaluations, but the facility did not create individualized care plans based on these recommendations, potentially affecting the residents' mental health needs.
Deficiencies in ROM and Mobility Care
Penalty
Summary
The facility failed to provide appropriate treatments and services to prevent or limit a decline in range of motion (ROM) and mobility for five residents. For Resident 95, the facility did not ensure that the Restorative Nursing Aide (RNA) order for the application of a resting hand splint was written with a maximal wear time, leading to uncertainty about the appropriate duration for splint use. This oversight could potentially result in skin breakdown and discomfort, as the RNA was not qualified to determine the wear time without specific instructions. Resident 19 did not receive passive range of motion (PROM) exercises for both arms as ordered, missing several scheduled sessions over three months. This lack of adherence to the physician's orders raised concerns about the resident's ROM, as the resident expressed worry about the infrequency of arm exercises. Similarly, Resident 37 missed multiple PROM exercise sessions for both arms and legs, which were not provided as per the physician's orders, potentially placing the resident at risk for functional decline. Residents 66 and 109 also experienced deficiencies in receiving ordered ambulation exercises. Resident 66 did not receive ambulation exercises using a front-wheeled walker as frequently as prescribed, and Resident 109 missed several sessions of ambulation exercises with hand-held assistance. These omissions in care could lead to a decline in mobility and overall physical functioning, as the facility's policies emphasize the importance of maintaining residents' current levels of function and preventing declines.
Improper Management of Tube Feedings in LTC Facility
Penalty
Summary
The facility failed to properly manage tube feedings for three residents with gastrostomy tubes, leading to potential risks of infection. For Resident 16, the tube feeding was not disconnected after administration, as observed by a Licensed Vocational Nurse (LVN). The Director of Nursing (DON) confirmed that leaving the tube connected could cause issues such as abdominal distention and restlessness. For Resident 84, the Jevity 1.5 feeding was observed to have been hanging for 48 hours, exceeding the manufacturer's recommended hang time of 24 hours. The DON acknowledged that the feeding should have been replaced the previous day to prevent gastrointestinal problems and diarrhea. Resident 37's tube feeding was also not replaced within the recommended time frame. An LVN noted that the feeding had been hanging for over 48 hours, contrary to facility policy and manufacturer guidelines. Additionally, the water bag lacked a label and should have been replaced every 24 hours. These practices were inconsistent with the facility's policy on enteral feeding safety precautions.
Failure to Document and Report Significant Weight Loss
Penalty
Summary
The facility failed to ensure that the Restorative Nurse Assistant (RNA 1) and licensed nurses, including Registered Nurses (RN 2 and RN 3), were competent in documenting and reporting significant weight changes for a resident. Resident 188, who was admitted with multiple health issues including a gastrostomy tube, muscle wasting, and non-Hodgkin lymphoma, experienced significant weight loss that was not properly documented or communicated to the registered dietician (RD), physician (MD 1), or the resident's family member (FM 1). The resident's weight loss was recorded in a handwritten document but was not entered into the electronic medical record, leading to a lack of timely intervention. The report highlights that the facility's staff did not follow the policy for documenting and reporting weight changes. Despite the resident's weight dropping from 119 lbs. to 93.2 lbs. over two months, the weight loss was not addressed in the resident's care plan, and the physician and family were not informed in a timely manner. The RNA verbally informed RN 3 of the weight loss, but it was not documented, and no action was taken to notify the physician or update the care plan. The RD was only made aware of the weight loss after reviewing the monthly weight report, which delayed the assessment and intervention. Interviews with staff revealed a lack of understanding and adherence to the facility's policies regarding weight monitoring and reporting. RN 2, the subacute unit manager, acknowledged that the facility did not complete a Change of Condition (COC) for weight loss unless it was a significant amount, and RN 3 admitted to not notifying the physician due to other duties. The Assistant Director of Nursing (ADON) emphasized the importance of documenting and monitoring significant weight loss, which was not done in this case, leading to further weight loss for Resident 188.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to ensure that Resident 177's physician order for Aspirin was administered correctly. The order specified that the Aspirin 81 MG tablet should be chewable, but it was observed that the resident swallowed the tablet instead. This was confirmed during an interview with RN 4, who acknowledged that the resident swallowed the aspirin, potentially affecting its efficacy. The Director of Nursing (DON) also stated that improper administration could lead to gastrointestinal stress and an increased risk of stroke. Resident 177 had a history of hypertension and hyperlipidemia and required supervision for eating and assistance with hygiene and bathing. The facility also failed to ensure the correct medication administration route for Resident 52, who had a gastrostomy tube and was unable to swallow by mouth. The physician order incorrectly indicated that Zinc Sulfate should be given orally, but LVN 3 had been administering it via the gastrostomy tube. LVN 3 acknowledged the error and the potential risk of aspiration if the medication were given orally. The DON emphasized the importance of verifying medication administration routes against physician orders and assessing the resident's condition to ensure accuracy. The facility's policy required that medication orders include the route of administration.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications according to manufacturer guidelines, which was observed during a survey. For Resident 152, an opened Budesonide inhalation suspension foil pack was found without an open date on the medication cart. The Registered Nurse (RN) acknowledged that the open date should have been written on the foil pack, as the medication must be used within two weeks after opening. This oversight could lead to the resident receiving expired medication, potentially affecting their treatment for shortness of breath. For Resident 1, an expired IV Tobramycin bag was found in the medication storage room refrigerator. The RN confirmed that the antibiotic was discontinued and should have been disposed of properly. Additionally, for Resident 72, an opened Ipratropium-Albuterol inhalation solution foil pack was found without an open date. The Licensed Vocational Nurse (LVN) stated that the open date should have been recorded to ensure the medication is used within the recommended timeframe, as per manufacturer guidelines. Furthermore, an opened Tuberculin Purified Protein Derivative (PPD) multi-dose vial was found with an open date, but it was not disposed of within the 30-day period as required. The Director of Nursing (DON) emphasized the importance of labeling medications and following storage guidelines to maintain potency and ensure accurate TB screening. The facility's policy and procedure documents also highlighted the need for proper medication storage and disposal, which were not adhered to in these instances.
Inaccurate Documentation of Joint Mobility Screenings
Penalty
Summary
The facility failed to ensure accurate completion and documentation of Physical Therapy Joint Mobility Screenings (PT JMS) for a resident, identified as Resident 19, who was part of a sample of seven residents. The PT JMS, dated 8/19/2024 and 10/15/2024, inaccurately indicated that Resident 19 had full passive range of motion (PROM) in both hips and knees and minimal range of motion (ROM) loss in both ankles. However, the screenings were conducted based on visual observation only, as Resident 19 refused the manual PROM assessment. This discrepancy was confirmed by Physical Therapist 1 (PT 1), who acknowledged that the assessments were inaccurate and should have documented the resident's refusal more clearly. Resident 19 had a medical history that included C1-C4 quadriplegia, polyneuropathy, and chronic obstructive pulmonary disease. The Minimum Data Set (MDS) assessment, dated 1/22/2025, indicated that Resident 19 was cognitively intact but dependent on assistance for daily activities and had functional ROM limitations in both arms and legs. The facility's policy required that joint mobility assessments be conducted upon admission, re-admission, quarterly, and upon a change of condition, with accurate documentation to ensure appropriate interventions and services. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the importance of accurate documentation in JMS evaluations to avoid missed opportunities for detecting declines in ROM and ensuring residents receive appropriate care. The facility's policy on Joint Mobility Assessment emphasized the need for accurate documentation to assist in developing or modifying care plans. The inaccurate documentation in Resident 19's PT JMS evaluations led to confusion and potential miscommunication among staff, highlighting a deficiency in the facility's documentation practices.
Failure to Address CPR and Weight Loss Concerns
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to identify and address concerns related to cardio-pulmonary resuscitation (CPR) and weight loss among residents. During an interview, the administrator admitted that these issues were not part of the current QAPI plan and were not identified before the recertification survey. The administrator acknowledged that these issues should have been detected through training and follow-through but were overlooked. A review of the facility's Quality Assurance and Performance Improvement (QAPI) Program policy indicated that the facility maintains an ongoing, facility-wide QAPI program focused on care outcomes and quality of life for residents. However, the program failed to measure and monitor indicators related to CPR and weight loss, which are critical for ensuring resident safety and well-being. This oversight had the potential to lead to continued weight loss and improper assessment skills for initiating CPR in full code residents.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control measures for several residents, leading to potential risks of infection transmission. Restorative Nursing Aide 2 did not wear an isolation gown while providing range of motion exercises to a resident on Enhanced Barrier Precautions (EBP). The aide was unaware of the resident's EBP status due to the sign being posted behind the bed, which was not visible upon entering the room. This oversight could have facilitated the spread of infectious microorganisms. Another deficiency involved the improper wrapping of padded side rails with foam and paper tape for a resident, which hindered effective cleaning and disinfection. The infection prevention nurse confirmed that the disinfectants used in the facility were only effective on hard, non-porous surfaces, making the foam and tape inappropriate for maintaining hygiene standards. This practice could lead to the spread of infection among residents and staff. Additionally, the facility failed to post EBP signage for a resident with a gastrostomy tube, foley catheter, and nephrostomy bag, and staff did not consistently wear proper PPE when interacting with residents on EBP. Observations revealed that staff members entered rooms without PPE and handled medical devices without performing hand hygiene, increasing the risk of cross-contamination. These lapses in protocol demonstrate a lack of adherence to infection prevention measures, potentially compromising resident safety.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program policy, resulting in the inappropriate use of antibiotics for two residents. Resident 154 was administered ceftriaxone for a urinary tract infection (UTI) despite not meeting Loeb's or McGeer's criteria for antibiotic use. The resident, who had a history of respiratory failure with hypoxia, tracheostomy, and gastrostomy, was dependent on assistance for hygiene, bathing, and dressing. The Infection Preventionist Nurse (IPN) noted that Resident 154's symptoms did not meet the criteria for antibiotic use, and there was no documentation indicating that the physician was notified of this discrepancy. Despite this, the resident completed the prescribed course of ceftriaxone. Similarly, Resident 29 was given cephalexin for a possible UTI without meeting the necessary criteria for antibiotic administration. This resident, diagnosed with dementia and hypertension, required supervision for eating and moderate assistance for hygiene, bathing, and dressing. The IPN confirmed that Resident 29's symptoms did not meet the criteria, and again, there was no documentation of physician notification. The Director of Nursing (DON) emphasized that the purpose of the antibiotic stewardship program is to ensure appropriate use of antibiotics and prevent overuse, highlighting the need for physician notification when criteria are not met.
Failure to Provide Oral Care for Hospice Resident
Penalty
Summary
The facility failed to provide adequate oral care for a resident under hospice care, compromising the resident's dignity and health. The resident, who was admitted with diagnoses including arteriosclerotic heart disease and Wernicke's encephalopathy, was dependent on staff for oral hygiene due to severe cognitive impairment and functional limitations. Despite physician orders and care plans indicating the need for oral care for comfort, observations revealed that the resident's teeth were covered with dried, sticky brown buildup, indicating a lack of oral care. Interviews with staff, including an LVN and the DON, confirmed that oral care is essential for maintaining dignity and preventing complications such as aspiration and infection. The facility's policies emphasized the importance of maintaining dignity and providing necessary care, yet the resident's Medication Administration Record showed that oral care was not provided as required. This oversight was observed over multiple days, with staff acknowledging the buildup and the potential risks associated with inadequate oral hygiene.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable physical well-being for a resident, identified as Resident 55, by not following facility policy and procedure to monitor and document assessments and interventions during a change of condition. The resident, who was admitted with diagnoses including protein-calorie malnutrition, major depressive disorder, and dysphagia, experienced significant weight loss over several months. Despite various dietary interventions being added to the care plan, the facility did not adequately monitor the resident's intake or adjust the care plan to address the actual weight loss. The facility's records indicated that Resident 55 had a history of poor oral intake and significant weight fluctuations, yet the care plan was not updated to reflect the actual weight loss. The resident's weight continued to decline, leading to the necessity of a gastrostomy tube to prevent further weight loss. Interviews with staff revealed that there was a lack of communication and documentation regarding the resident's food and supplement intake, and the care plan was not revised to address the ongoing weight loss. The facility's policies required that significant weight changes be reported and addressed by the multidisciplinary team, but this was not consistently done. The resident's weight loss was not adequately monitored, and the care plan was not updated to reflect the resident's needs, resulting in a failure to provide appropriate care. The facility's failure to implement a patient-centered care plan and monitor the resident's condition contributed to the resident's continued weight loss and subsequent medical intervention.
Resident Prescribed Unnecessary Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antipsychotic medications. Resident 188, who was admitted with diagnoses including gastrostomy tube, muscle wasting, non-Hodgkin lymphoma, tracheostomy tube, and multiple pressure ulcers, did not have any documented mental health issues or psychosis. Despite this, the resident was prescribed Seroquel, an antipsychotic medication, without an adequate diagnosis or indication for its use. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment but no signs of psychosis or behavioral symptoms that would justify the use of antipsychotic medication. The Assistant Director of Nursing (ADON) confirmed that there was no diagnosis for psychosis or mental health issues in Resident 188's chart, and the order for Seroquel lacked a complete manifestation statement. This oversight placed the resident at risk for harmful side effects associated with antipsychotic medications, including sedation, drowsiness, dizziness, and an increased risk of death as indicated by the black box warning on Seroquel. The facility's policy on antipsychotic medication use required that medications be clinically indicated for a specific condition, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Long Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewater Skilled Nursing Center | 0.6 mi | ★★★★★ | 21 | 0 |
| Long Beach Post Acute | 0.6 mi | ★★★★★ | 18 | 0 |
| Villa Serena Healthcare Center | 0.7 mi | ★★★★★ | 16 | 0 |
| Broadway By The Sea | 0.8 mi | ★★★★★ | 26 | 0 |
| Alamitos Belmont Health And Rehabilitation | 1.2 mi | ★★★★★ | 16 | 1 |
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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.