Downey Community Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Downey, California.
- Location
- 8425 Iowa Street, Downey, California 90241
- CMS Provider Number
- 555128
- Inspections on file
- 37
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Downey Community Health Center during CMS and state inspections, most recent first.
Nursing staff were not aware of the meaning of visual identifiers, such as a 5-fingers sign indicating the need for more than two-person assistance during transfers, despite having attended relevant in-service training. This lack of awareness was confirmed through interviews and review of facility policies and training records.
A Restorative Nurse Aide documented that restorative care services, including PROM exercises and PRAFO application, were provided to a resident with severe cognitive impairment and mobility limitations, when these services were not actually performed due to staffing shortages. The RNA later confirmed the documentation was inaccurate, and facility policy requires all medical record entries to be complete and accurate.
A resident with cognitive impairment and total dependence for transfers was moved from a wheelchair to a bed using a Hoyer Lift by a CNA without the required second staff member. Staff interviews and documentation confirmed that a two-person assist was necessary per care plan, facility policy, and manufacturer guidelines, but this protocol was not followed during the transfer.
Surveyors found that the Infection Preventionist Nurse did not complete the required ten hours of annual continuing education in Infection Prevention and Control after certification, as confirmed by both interview and record review. This failure was contrary to state guidance and the facility's job description, which require ongoing education for the role.
Staff training on abuse reporting did not align with federal guidelines, as the lesson plan instructed staff to report abuse allegations within 24 hours instead of the federally required two-hour timeframe. The DON and DSD confirmed the lesson plan was based on state guidance and facility policy, but neither was certain of the federal requirements. Facility policies referenced compliance with both state and federal regulations, but the actual training provided to staff was inconsistent with federal mandates.
Kitchen staff did not consistently wear required hair coverings in food service and preparation areas, as observed when a dishwasher worked without proper hair netting. Additionally, a large container of powdered nutritional supplement in the dry storage room was found unlabeled and undated, contrary to facility policy requiring all food items to be labeled and dated.
A resident with dementia and a primary language of Spanish was provided an English-only Arbitration Agreement, which she could not understand or remember signing. The facility did not have a Spanish version available, despite policy requiring explanation in a language the resident understands.
A resident with severe cognitive impairment, muscle weakness, and a history of falls was observed twice with her call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible. Both a CNA and an LVN confirmed the call light was not within reach and acknowledged the importance of its placement for resident safety.
A resident with severe cognitive impairment and multiple medical conditions developed skin tears and bleeding on both forearms after striking bed siderails during care. The CNA who discovered and dressed the wounds did not report the incident to licensed staff, resulting in delayed notification to the physician and the resident's representative. The deficiency was identified when the resident's representative noticed the injuries and questioned staff, revealing a lack of timely communication and documentation.
A resident with a history of psychosis, dementia, schizophrenia, and major depressive disorder was prescribed an antidepressant for depression, but the MDS assessment failed to include depression as an active diagnosis. The MDS Coordinator confirmed this omission was an error, despite facility policy requiring accurate and comprehensive assessments.
A resident admitted with multiple diagnoses, including neuropathic pain, was prescribed Pregabalin, but staff failed to develop and implement a care plan for this medication. Both an LVN and the DON confirmed the absence of a care plan, despite facility policy requiring one for proper monitoring and intervention.
A resident with a history of stroke and hemiplegia was on dual antiplatelet therapy with aspirin and clopidogrel, as ordered by the physician. However, the care plan included an intervention to avoid aspirin, which conflicted with the resident's prescribed treatment. The care plan was not revised to reflect the concurrent use of both medications, leading to potential confusion among licensed nurses regarding the resident's antiplatelet therapy.
Two residents with severe cognitive impairment and multiple medical conditions were observed with long, dirty fingernails, despite care plans and facility policies requiring staff to assist with daily grooming and nail care. CNAs acknowledged responsibility for nail hygiene but did not ensure the residents' fingernails were kept clean and trimmed.
Two residents receiving controlled medications for pain management did not have their medication administrations properly documented on the Controlled Drug Record by nursing staff, resulting in discrepancies between the recorded and actual counts of medication doses. Nurses acknowledged the omissions and confirmed that facility policy required accurate documentation of each dose removed.
A resident receiving Pregabalin for neuropathic pain was not monitored for sedation as required by physician orders and facility policy. Despite repeated observations of the resident lying in bed with eyes closed, there was no documentation on the MAR of monitoring for sedation or holding the medication, and staff interviews confirmed the lack of required monitoring.
A resident with diabetes did not receive glipizide as ordered, with the medication being administered significantly earlier than 30 minutes before breakfast. Despite the resident's requests and physician instructions, nursing staff gave the medication at a set time rather than in relation to mealtime, and did not offer alternatives such as a snack or adjusting the administration time. Staff interviews confirmed a lack of adherence to physician orders and facility policy, resulting in a significant medication error.
A resident with severe cognitive impairment was observed with outside food left at the bedside for approximately four hours, contrary to facility policy requiring removal or refrigeration of perishable items after two hours. Staff did not check, remove, or properly store the food, and interviews confirmed that this practice did not align with established procedures for food safety.
A resident's Advance Directives Acknowledgement form was found incomplete, missing required initials, despite facility policy requiring complete and accurate medical records. The Admission Coordinator confirmed responsibility for the oversight, and the resident had multiple medical conditions and was dependent on staff for daily care.
A resident with hemiplegia and impaired cognitive skills was unable to use the standard call light system due to limited hand function. Staff were aware of the issue but did not report it or provide an alternative, such as a touch pad call light, as required by facility policy. The deficiency was identified through observation, interviews, and record review.
Facility staff did not report an allegation of resident-to-resident physical abuse to the State Agency within the required two-hour timeframe. Two residents with mental health diagnoses were involved in an altercation, but the incident was only reported after a surveyor's inquiry, resulting in delayed notification to authorities.
A resident with intact cognition and multiple medical conditions alleged that a CNA physically abused her during care. Despite the report, the CNA was not immediately removed from duty and continued to care for the resident's roommates. Facility staff did not investigate the allegation promptly, contrary to policy requiring immediate action when abuse is reported.
A resident with multiple medical conditions reported being hit by a CNA and expressed a preference not to have that CNA assigned. The incident and the resident's concerns were not documented in the medical record or progress notes, and a change of condition following an abuse allegation was also not recorded per shift as required. The DON confirmed that documentation was incomplete and did not meet facility policy or standard practice.
A resident with diabetes was not monitored for blood sugar levels as ordered by the physician over a three-day period following readmission from a hospital. Despite clear orders for insulin administration based on a sliding scale and regular blood sugar checks, nursing staff did not perform or document these checks. The omission was confirmed by staff interviews and facility records, and the resident ultimately experienced a significant hyperglycemic episode, requiring transfer to a hospital.
A resident was denied readmission to a facility after hospitalization, despite being medically cleared and having available beds. The facility cited a lack of isolation beds due to the resident's history of MDRO, although the MDRO was not active. The facility's policy prioritizing readmission was not followed, leading to the resident staying at the hospital longer than necessary.
The facility failed to post required signage for two residents on Enhanced Barrier Precautions (EBP), which necessitates the use of gowns and gloves to prevent the spread of multidrug-resistant organisms. Both residents required EBP due to medical conditions involving a jejunostomy tube and a Foley catheter, respectively. Observations revealed the absence of signage at their room entrances, a deficiency confirmed by the Infection Prevention Nurse and Director of Nursing, contrary to the facility's policy.
The facility failed to implement the care plan intervention of bilateral floor mats for a resident identified as high risk for falls. Despite a doctor's order and the facility's policy, the fall mats were not properly placed, potentially putting the resident at risk of injury.
The facility failed to implement infection control practices, including Enhanced Barrier Precautions and proper use of PPE during wound care for two residents. Additionally, staff did not follow hand hygiene policies during a medication pass for another resident.
The facility failed to ensure home medications were reviewed by a pharmacist before administration and did not accurately document the administration of Lorazepam, a controlled medication, for two residents. This led to potential medication errors and increased health risks.
The facility failed to ensure proper documentation and monitoring of lorazepam use for a resident with paranoid schizophrenia, leading to potential medication errors and an unwitnessed fall. The LVN admitted to not documenting the administration and effectiveness of the medication, and non-pharmacological interventions were not attempted prior to administration.
The facility failed to maintain a medication error rate of less than 5% during medication pass for four of five sampled residents. Errors included crushing non-crushable medications, late administration of Metformin, incorrect dosing of docusate sodium, improper resident identification, and not shaking liquid medications before administration.
The facility failed to prepare pureed food with the required smooth texture for 23 residents, resulting in lumpy and chunky lasagna that required chewing. This was confirmed by the Dietary Supervisor and Registered Dietitian, posing a choking risk for residents with swallowing difficulties.
The facility failed to ensure safe and sanitary food storage and preparation practices, including storing expired and undated food items, maintaining an unclean dry storage area, and using previously cooked ground beef without proper documentation and monitoring. The Dietary Supervisor acknowledged these issues and stated that the items should be discarded and that all food should be labeled, dated, and covered during storage to prevent cross-contamination and ensure food safety.
The facility failed to inform a resident of the medications being administered prior to administration, violating the resident's right to be informed and to participate in their care. An LVN was observed giving a resident a medicine cup containing pills without explanation, and the resident expressed a desire to know what medications he was taking. Interviews with staff confirmed this was against facility policy.
A resident with intact cognitive skills and multiple diagnoses was served meals with plastic utensils without being informed of the reason, leading to feelings of distress. Staff were unaware of the reason for the use of plastic utensils, and there was no documentation to support this intervention, violating the facility's dignity policy.
A resident's right to privacy was violated when the case manager repeatedly opened the resident's mail without permission, despite the resident's intact cognitive skills and capacity to make decisions. The case manager admitted to the actions, which were against the facility's policy and procedure on mail handling.
The facility failed to develop and implement a care plan for a resident with suicidal ideations, despite the resident expressing a desire to harm herself due to feeling anxious and sad. The resident's records and staff interviews confirmed the absence of a care plan addressing her mental health needs, which was a significant oversight.
The facility failed to maintain appropriate grooming and personal hygiene for two residents, leading to dirty and untrimmed nails. Despite staff acknowledging the issue and the facility's policy requiring daily nail care assessment, the residents' nails were not cleaned or trimmed, posing a risk of infection and negatively impacting their quality of life.
A facility failed to conduct a Post-Fall Assessment and IDT meeting after a resident with severe cognitive impairment and mobility issues experienced an unwitnessed fall. The necessary assessments and meetings were not completed, increasing the risk of future falls and injury for the resident.
A resident received Potassium Chloride ER in a crushed form mixed with other medications, contrary to the manufacturer's specifications and the facility's policy. The error was observed during a survey, and the resident's medical records showed multiple instances of this improper administration. LVNs admitted to the mistake, and the DON confirmed the facility's guidelines against crushing certain medications.
A resident with missing teeth and on a mechanical soft diet was repeatedly served tortillas that were too hard to chew, leading her to only eat the filling and leaving the tortillas uneaten. Interviews with staff confirmed that this placed the resident at risk of choking and aspiration.
A resident with severe cognitive and physical impairments was provided with a standard call light system they were unable to use. Despite the resident's inability to activate the call light due to weakness in their hands and fingers, no action was taken to provide a more suitable system, such as a touch pad call light. Interviews with staff confirmed the need for a more appropriate call light system, as per the facility's policy.
Staff Unaware of Visual Identifier Meanings for Resident Care
Penalty
Summary
The facility failed to ensure that nursing staff, specifically Certified Nurse Assistants (CNAs), were aware of the meaning of visual identifiers posted in resident rooms, which are intended to communicate special needs or accommodations for residents. During interviews, a CNA was unable to identify the significance of a 5-fingers visual identifier, which, according to facility policy, indicates that a resident requires more than two persons for assistance during transfers. Despite having attended an in-service training on visual identifiers, the CNA did not recall the meaning of the sign when questioned. A review of the facility's lesson plan and policy confirmed that staff are expected to check for visual identifiers before providing care and to follow any associated precautions. The Director of Staff Development stated that staff are expected to apply what they learn in training to their daily practice to ensure resident and staff safety. However, the lack of staff awareness regarding the visual identifier demonstrates a failure to ensure that staff have the necessary competencies to provide appropriate care for residents as outlined in facility policy.
Inaccurate Documentation of Restorative Care Services
Penalty
Summary
A deficiency occurred when a Restorative Nurse Aide (RNA) documented that restorative care services, specifically passive range of motion (PROM) exercises and the application of a Pressure Relief Ankle Foot Orthosis (PRAFO), were provided to a resident, when in fact these services were not performed. The resident in question had significant cognitive impairment, was unable to make or understand decisions, and had diagnoses including osteoporosis and rheumatoid arthritis, with documented limitations in range of motion. The resident's care plan included physician orders for PROM and PRAFO application five times per week. However, on the date in question, the RNA signed off in the RNA Program Administration Report as if the tasks were completed, despite not having seen the resident or performed the ordered interventions due to insufficient staffing. During interviews, the RNA admitted to signing off on the tasks without performing them and acknowledged that the documentation should have reflected the missed care and the reason for it. The Director of Staff Development confirmed that documentation should always be accurate and never indicate that care was provided when it was not. The facility's policy and procedures also required that documentation in the medical record be objective, complete, and accurate. This inaccurate documentation practice was identified through record review and staff interviews.
Failure to Use Two-Person Assist During Hoyer Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to use a required two-person assist during a Hoyer Lift transfer for a resident with significant cognitive and physical impairments. The resident, who had diagnoses including metabolic encephalopathy, vascular dementia, and cerebral infarction, was dependent on staff for all transfers and unable to make decisions or support himself. Despite care plan interventions and physical therapy recommendations indicating the need for full assistance, a certified nursing assistant (CNA) transferred the resident from a wheelchair to a bed using the Hoyer Lift without a second staff member present. Multiple interviews confirmed that facility policy, the resident's care plan, and the manufacturer's guidelines all required two staff members for Hoyer Lift transfers to ensure safety. The CNA, as well as other staff including an LVN, RN, DON, and Director of Rehab, acknowledged that a two-person assist was necessary for this resident due to his cognitive and physical limitations. The incident was directly observed and reported by the responsible party, and documentation supported that the resident was fully dependent and at risk during transfers.
Plan Of Correction
Corrective Action: Res1 is currently in the hospital. RN will assess Res 1 regarding transfer assistance needs upon return. On 7/31/25, the DON/DSD provided CNA1 1:1 service/disciplinary action regarding the need to exercise clinical judgement when operating a Hoyer lift with another staff. How to Identify Potentially Affected: On 7/29/25, the charge nurses checked other residents requiring Hoyer lifts for transfers to ensure the staff is operating it safely, with another staff assisting as needed. No similar issues identified. Systematic Change: On 7/30-31, 2025, the DSD/Designee (Director of Staff Developer) in-serviced the licensed nurses and licensed nurses on the facility's policy on operating Hoyer lifts with additional staff based on staff's clinical judgment, to ensure resident's safety. The facility will continue to have visual identifiers for the use of Hoyer lifts to alert CNAs and Licensed nurses. The DSD will complete the CNAs' skills competency on how to safely operate the Hoyer lift upon hire, annually, and as needed. MONITORING: The DON/Supervisors/Charge Nurses will monitor compliance with proper use of Hoyer lifts through routine rounds. The facility will conduct a QA study on staff compliance to the use of Hoyer lifts in the next 30 days or until acceptable compliance is achieved. If lack of compliance is identified, revisions will be made as needed. Trends and findings will be reported to the QA committee for further recommendations. Completion date: 8/10/25
Infection Preventionist Lacked Required Continuing Education
Penalty
Summary
The facility failed to ensure that the Infection Preventionist Nurse (IPN) completed the required ten hours of continuing education in Infection Prevention and Control within a year of certification. During an interview and record review, the IPN confirmed that after completing the Nursing Home Infection Preventionist Training Course certification, no further documented continuing education in the field had been completed. The IPN acknowledged responsibility for maintaining at least ten hours of annual continuing education to stay current with guidelines and protocols, and admitted that this requirement had not been met. A review of the California Department of Public Health's All Facilities Letter and the facility's Infection Control Coordinator Job Description both indicated the necessity for ongoing education in infection prevention and control. The job description specifically stated that the Infection Control Coordinator is responsible for promoting professional growth and development through educational activities and participation in trainings. The lack of documented continuing education for the IPN was directly observed and confirmed during the survey process.
Inconsistent Staff Training on Abuse Reporting Timelines
Penalty
Summary
The facility failed to ensure that staff training on abuse reporting was consistent with federal reporting guidelines. During interviews and record reviews, it was found that the lesson plan used for staff education indicated that allegations of abuse were to be reported to the State Agency within 24 hours unless the allegation involved injury. Both the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the lesson plan was based on state guidance and facility policy, but neither was certain of the specific federal requirements. The DON stated that the lesson plan was reviewed and approved for staff education, and the DSD acknowledged the importance of timely reporting to ensure resident safety. Further review of facility policies and the All Facilities Letter (AFL) 21-26 revealed that federal guidelines require all allegations of abuse to be reported to the State Agency within two hours, not 24 hours as taught in the lesson plan. The Administrator (ADM) also stated that the facility's policy was to report resident-to-resident altercations within two hours, and the facility's policy and procedure documents referenced compliance with both state and federal regulations. However, the training provided to staff did not align with these federal requirements, creating a risk of delayed reporting and investigation of abuse allegations.
Failure to Ensure Proper Hair Covering and Food Labeling in Dietary Services
Penalty
Summary
Kitchen staff failed to consistently wear hair coverings while working in food service and preparation areas. During an observation, a dishwasher was seen without the required hair covering in the dishwashing area near the food preparation station. The staff member stated he was unaware that his hair netting had fallen and believed his hair was still covered. The dietary supervisor confirmed that a hair covering not properly secured could result in hair falling into food, clean dishes, or food preparation areas, which increases the risk of food contamination. Additionally, in the dry food storage room, a large plastic container filled with a powdered substance was found to be unlabeled and undated. The dietary supervisor identified the substance as a powdered nutritional supplement and acknowledged that it should have been labeled and dated according to facility protocol. Facility policies reviewed indicated that all food items in the storeroom should be labeled and dated, and that food delivered to the facility should be marked with a received date.
Failure to Provide Arbitration Agreement in Resident's Preferred Language
Penalty
Summary
The facility failed to ensure that a resident with a primary language of Spanish fully understood the binding Arbitration Agreement at the time of admission. The resident, who had diagnoses including major depressive disorder and dementia with moderately impaired cognition, required an interpreter to communicate with healthcare staff and preferred to receive information in Spanish. Despite this, the Arbitration Agreement was only provided in English, and the resident signed the agreement without a Spanish version being available. During interviews, the resident stated she did not remember the arbitration agreement, could not read English, and would have preferred the agreement in Spanish for better understanding. The Admission Coordinator confirmed that the Arbitration Agreement was only available in English and acknowledged that the facility should have provided it in Spanish for residents whose primary language was Spanish. Facility policy required that agreements be explained in a language the resident understands, but this was not followed in this instance.
Call Light Not Within Reach for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident's call light was not within reach on two separate occasions. During observations, the call light cord was found hanging from the left-upper side rail with the touch pad touching the floor, making it inaccessible to the resident. The resident was awake and lying in bed during both observations. The resident's care plan specifically indicated that the call light should be within reach due to her high risk for falls. The facility's policy also required staff to check call light placement during rounds to ensure it was accessible. The resident involved had diagnoses of generalized muscle weakness, dementia with severely impaired cognition, and a history of falls. She was dependent on staff for all self-care and mobility needs and lacked the capacity to make decisions. Interviews with a CNA and an LVN confirmed that the call light was not within reach and acknowledged that it should have been accessible for the resident's safety. Both staff members stated that checking call light placement was part of their routine responsibilities.
Failure to Promptly Notify Physician and Representative of Resident's Change in Condition
Penalty
Summary
The facility failed to promptly notify the physician and the resident's representative of a significant change in condition involving a resident who developed skin tears and bleeding on both forearms. The resident, who had diagnoses including dementia, cerebrovascular accident, major depression, diabetes mellitus, and hypertension, was assessed as severely cognitively impaired and unable to make decisions. The care plan required monitoring for skin breakdown and reporting injuries to the physician. Despite this, the resident was found with dressings on both forearms, and neither the physician nor the resident's representative was informed in a timely manner. Interviews and record reviews revealed that the skin tears and bleeding occurred after the resident struck her arms on the bed siderails during personal care. The CNA who discovered and dressed the wounds did not report the incident to licensed nursing staff out of fear of suspension. The incident was only brought to the attention of the treatment nurse and subsequently the director of nursing after the resident's representative noticed the dressings and inquired about them. Documentation in the electronic medical record did not indicate how the injuries occurred or who applied the dressings, and there was no evidence of timely notification to the physician or the resident's representative, contrary to facility policy.
Inaccurate MDS Assessment for Depression Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's diagnosis of depression. The resident, who had a history of psychosis, dementia, and schizophrenia, was readmitted to the facility with documented diagnoses that included major depressive disorder. Medical records, including a psychiatric evaluation and physician orders, indicated the resident was prescribed bupropion, an antidepressant, specifically for depression. Despite this, the MDS assessment did not include depression as an active diagnosis. During an interview and record review, the MDS Coordinator confirmed that the omission of the depression diagnosis from the MDS was an error, acknowledging that the resident's use of antidepressant medication and documented diagnosis warranted its inclusion. The facility's policy requires comprehensive and accurate assessments to guide care planning, but this was not followed in this instance, resulting in an incomplete assessment for the resident.
Failure to Develop and Implement Care Plan for Prescribed Medication
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a care plan for a resident who had been prescribed Pregabalin to treat neuropathic pain. The resident was admitted with multiple diagnoses, including arthritis, muscle weakness, polyneuropathy, and acute pulmonary edema. Documentation showed that the resident had intact cognition and required maximal assistance with activities of daily living. Despite a physician's order for Pregabalin, there was no corresponding care plan outlining the medication's use, monitoring parameters, potential side effects, or necessary interventions. During interviews, both a Licensed Vocational Nurse and the Director of Nursing confirmed that a care plan for Pregabalin was not present in the resident's records. The facility's policy required care plans to be initiated upon admission and revised as needed to ensure proper delivery of care. The absence of a care plan for this medication was acknowledged by staff and was not in accordance with facility policy.
Failure to Revise Care Plan for Dual Antiplatelet Therapy
Penalty
Summary
The facility failed to revise the person-centered care plan for a resident who was on dual antiplatelet therapy with aspirin and clopidogrel. The resident had a history of stroke, hemiplegia, and hemiparesis, and was receiving both medications for stroke prophylaxis as ordered by the physician. The care plan, however, included a standardized intervention to avoid the use of aspirin, which conflicted with the resident's current medication orders. The Minimum Data Set Coordinator confirmed that the care plan should have been revised to reflect the concurrent use of both antiplatelet medications, as the resident had been on this therapy since admission. This discrepancy in the care plan had the potential to cause confusion among licensed nurses regarding the appropriate administration of the resident's antiplatelet therapy. The facility's policy required care plans to be updated with new interventions as necessary, but the care plan for this resident was not revised to accurately reflect the physician's orders and the resident's current treatment regimen.
Failure to Maintain Resident Nail Hygiene and Grooming
Penalty
Summary
The facility failed to provide adequate care and services to maintain good grooming and personal hygiene for two residents who were unable to perform these tasks independently. Observations revealed that both residents had long fingernails with visible dirt or black substance underneath. One resident, who had diagnoses including diabetes mellitus, hypertension, and dysphagia, was noted to have severely impaired cognitive skills and required maximal assistance with activities of daily living (ADLs). Despite a care plan indicating daily assistance with ADLs, the resident's fingernails remained untrimmed and unclean. Certified Nursing Assistants (CNAs) acknowledged responsibility for daily nail care and recognized the importance of keeping fingernails clean to prevent infection. Another resident, with diagnoses including schizoaffective disorder, dementia, bipolar disorder, and diabetes mellitus, also had severely impaired cognitive skills and required supervision or touching assistance for ADLs. This resident was observed with long, dirty fingernails, and staff confirmed the condition and the associated risks. The care plan for this resident also specified daily assistance with ADLs and nail care as needed. Facility policy and CNA job descriptions required assistance with personal grooming, including nail care, but these standards were not met for the two residents identified.
Failure to Accurately Document Controlled Drug Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation on the Controlled Drug Record for two residents who were receiving controlled medications for pain management. In the first instance, a resident with diagnoses including radiculopathy, cervicalgia, and low back pain was prescribed pregabalin 25mg three times daily. After administration of the morning dose, the nurse did not document the removal of the medication on the Controlled Drug Record, resulting in a discrepancy between the number of doses recorded and the actual number left in the bubble pack. The nurse acknowledged the omission and confirmed that facility procedure required documentation of each dose removed. In the second instance, another resident with a history of surgical amputation and a stage three pressure ulcer was prescribed tapentadol 100mg twice daily. The nurse administered the medication but failed to document it on the Controlled Drug Record, leading to an inaccurate count of remaining doses. Both nurses involved stated they were responsible for documenting each administration on the Controlled Drug Record as per facility policy, which was not followed in these cases. The facility's policy required licensed nurses to record administered controlled medications on both the MAR and the narcotic count sheet.
Failure to Monitor for Sedation with Pregabalin Administration
Penalty
Summary
The facility failed to monitor a resident for signs of overmedication while the resident was prescribed Pregabalin for neuropathic pain. Multiple observations over several days showed the resident lying in bed with eyes closed, suggesting possible sedation. The resident's physician order included parameters to hold Pregabalin if sedation occurred, but there was no documentation on the medication administration record (MAR) indicating that monitoring for sedation was performed or that the medication was held as directed. The resident had a history of arthritis, muscle weakness, polyneuropathy, and acute pulmonary edema, and was assessed as having intact cognition but requiring maximal assistance with activities of daily living. Interviews with nursing staff and the DON confirmed the importance of monitoring for sedation and following physician orders, but also revealed that no documentation of such monitoring was present. The facility's policy required monitoring and documentation of medication side effects, which was not followed in this case.
Failure to Administer Glipizide According to Physician's Orders
Penalty
Summary
A deficiency occurred when a resident with diabetes mellitus and a history of long-term insulin use did not receive glipizide as ordered by the physician. The physician's order specified that glipizide should be administered 30 minutes before breakfast and dinner. However, the Medication Administration Record and audit reports showed that the medication was consistently given at 6:30 a.m., while the earliest breakfast was served at 8:00 a.m., resulting in the medication being administered up to one and a half hours before the resident ate. The resident expressed concerns to staff about the timing of the medication, stating that she was instructed by her physician to take glipizide within 30 minutes before breakfast and that taking it earlier could jeopardize her health. Despite her requests, nurses insisted on administering the medication at the scheduled time and did not offer it closer to breakfast or provide a snack. The resident did not refuse the medication but asked for it to be given at the appropriate time, and when this was not accommodated, she considered refusing it for her safety. Interviews with nursing staff revealed a lack of awareness regarding the resident's concerns and the physician's specific timing instructions. Staff acknowledged that medications intended to be given before meals should be administered closer to mealtime or with a snack if necessary, but this was not done. Facility policies required nurses to follow physician orders and to re-offer medications if initially refused, but these procedures were not followed in this case, resulting in a significant medication error.
Failure to Remove Perishable Outside Food from Resident Bedside
Penalty
Summary
The facility failed to follow its policy regarding the removal and storage of outside food brought in for a resident. Specifically, a resident with severe cognitive impairment and a regular diet order was observed receiving outside food, which remained at the bedside for approximately four hours. Staff did not check or remove the food within the required timeframe, as outlined in the facility's policy, which states that potentially hazardous foods left out for more than two hours without refrigeration or a heat source must be discarded. Interviews with staff, including an LVN and the Dietary Supervisor, confirmed that outside food should not be left at the bedside for more than one to two hours due to the risk of spoilage. The Dietary Supervisor also noted that perishable items, such as chili with cheese, should be refrigerated, labeled, and monitored. Despite these procedures, the food was left at the resident's bedside well beyond the allowed period, and staff did not intervene to remove or properly store the food.
Incomplete Advance Directives Documentation in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident. Specifically, the Advance Directives Acknowledgement (ADA) form for a resident was found to be incomplete, missing the resident's initials. The Admission Coordinator, who was responsible for completing the ADA form upon admission, confirmed during an interview and record review that the form was not properly filled out. The ADA form is a legal document included in the resident's medical record and is intended to reflect the resident's medical needs and wishes. The resident involved had a history of major depressive disorder, gastrostomy, and anemia, and was dependent on staff for activities of daily living, though their cognitive skills were intact. The facility's policy required that medical records be complete and accurate, but this was not followed in this instance, resulting in an incomplete legal document within the resident's file.
Failure to Provide Accessible Call Light System for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with left body hemiplegia and right-sided weakness was unable to use the standard call light system in their room. Observations showed the call light was placed near the resident's left hand, but the resident was unable to press the button due to limited finger movement. The resident was dependent on staff for most activities of daily living and had impaired cognitive skills, as documented in their medical records and assessments. Despite these limitations, the call light system provided was not accessible to the resident. Interviews with staff revealed that the certified nursing assistant (CNA) was aware the resident could not use the call light but did not notify the charge nurse or maintenance to obtain an alternative system, such as a touch pad call light. The facility's policy required staff to assess residents' ability to use the call system and to provide alternatives if needed, but this was not followed. The director of staff development and a registered nurse both confirmed the importance of ensuring residents can use their call lights, but in this case, the necessary accommodations were not made.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
Facility staff failed to report an allegation of resident-to-resident physical abuse to the State Agency within the required two-hour timeframe for two residents. One resident, with a history of schizoaffective disorder, paranoid schizophrenia, and psychosis, reported that her previous roommate threw a chair at her. The incident was not reported to the State Agency until the surveyor brought it to the attention of the facility's social worker and program director. The facility's policy and process require that such allegations be reported within two hours, but the mandated reporting form (SOC-341) was not sent until several hours after the allegation was made known to staff. The records reviewed indicated that both residents involved had significant mental health diagnoses but were assessed as not having cognitive impairments. The incident was only discovered after a resident disclosed the altercation during an interview with the surveyor, and the facility's documentation showed the resident had been moved to another room due to incompatibility, without any prior report of abuse. The delay in reporting was confirmed by interviews with facility staff, including the program director and administrator, who acknowledged the requirement for timely reporting and the failure to meet it in this case.
Failure to Remove CNA After Abuse Allegation
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was immediately removed from access to a resident after an allegation of physical abuse was made. A resident, who was alert, oriented, and had intact cognition, reported to the Social Service Designee that the CNA hit her on the back, pressed on her back while in bed, and pushed her during a transfer, resulting in her hitting her head on the side rail. The resident also reported that the CNA told her to be quiet and not to scream. The incident was reported to a nurse, but the CNA continued to work the remainder of the shift and was still assigned to care for the resident's roommates after the allegation was made. Interviews and record reviews revealed that the nurse did not investigate the allegation or ask the resident about the incident, attributing the request for a different CNA to the resident's baseline behavior of having preferred caregivers. The facility's policy required immediate investigation and reassignment or suspension of employees accused of abuse, but this was not followed. As a result, the CNA remained on duty and continued to provide care to other residents in the same room as the alleged victim after the abuse allegation was reported.
Failure to Document Resident Concerns and Change of Condition
Penalty
Summary
The facility failed to maintain complete and accurate documentation for a resident who reported concerns regarding care provided by a CNA. The resident, who had diagnoses including low back pain, muscle weakness, and diabetes mellitus, and was cognitively intact, reported to a social service designee that a CNA hit her on the back and pressed on her back while in bed. The resident stated she informed a nurse about the incident, but there was no documentation in the resident's progress notes regarding her concerns or the incident. The Director of Nursing confirmed that such concerns should have been documented as a grievance and in the progress notes to ensure appropriate follow-up and staff education, but this was not done. The only documentation found was in the 24-hour communication log, noting the resident's request not to have the CNA assigned, which the DON attributed to the resident's baseline behavior rather than a specific concern. Additionally, the facility did not document a change of condition after the resident alleged abuse by the CNA. Although a Change of Condition assessment was completed, there was no corresponding documentation in the nursing progress notes for the relevant shift. The DON acknowledged that nurses are required to document per shift and as needed when there is a change of condition, and that this documentation is essential for resident safety and continuity of care. The facility's policies and the LVN job description both require complete and timely documentation, which was not met in this instance.
Failure to Monitor Blood Sugar as Ordered for Diabetic Resident
Penalty
Summary
The facility failed to follow professional standards of practice by not implementing a physician's order to monitor a resident's blood sugar (BS) levels on three consecutive days. The resident, who had a history of diabetes mellitus type 2, hypertension, and anxiety disorder, was readmitted to the facility with orders from a general acute care hospital to continue insulin administration based on a sliding scale, with BS checks before meals and at bedtime. Despite these clear orders, the Medication Administration Record (MAR) and blood sugar summary showed that the resident's BS levels were not checked as ordered on 2/28/2025, 3/1/2025, and 3/2/2025. The omission was confirmed through interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Registered Nurse (RN), and the Director of Nursing (DON), all of whom acknowledged that the resident's BS was not monitored during the specified period. The LVN explained that the absence of documentation in the MAR indicated that the checks were not performed, and the DON confirmed that the failure to monitor BS could result in unrecognized hypoglycemia or hyperglycemia. The resident reported that after returning from the hospital, BS checks stopped for two days, and only resumed after the resident requested it due to feeling unwell. On 3/2/2025, the resident experienced a change of condition, with a recorded BS level of 491 mg/dl, and subsequently requested transfer to a hospital. Facility policy and procedures reviewed indicated that care should be provided in accordance with physician orders, and that the frequency of BS monitoring is determined by the physician and must be documented by licensed nurses. The failure to follow these standards resulted in the resident experiencing a hyperglycemic episode and requiring hospital transfer.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, despite having available beds and the resident being medically cleared for discharge. The resident, who had a history of right hemiplegia and chronic kidney disease, was transferred to a General Acute Care Hospital (GACH) for symptoms of wheezing and shortness of breath. After treatment, the resident was deemed appropriate for discharge back to the facility. However, the facility denied readmission, citing a lack of isolation beds due to the resident's history of multidrug-resistant organisms (MDRO), even though the MDRO was not active. Interviews with facility staff revealed that the Admission Coordinator informed the Director of Nursing (DON) that the resident did not require isolation, but the DON insisted on an isolation bed. The facility's census showed available beds, yet the DON did not allow the resident to return. The facility's policy stated that residents discharged to the hospital should be given priority for readmission, but this was not followed, resulting in the resident remaining at the hospital for two additional days.
Failure to Implement Enhanced Barrier Precautions Signage
Penalty
Summary
The facility failed to implement its infection prevention and control measures by not ensuring clear signage was posted for two residents who were on Enhanced Barrier Precautions (EBP). These precautions require the use of gowns and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms (MDROs). The absence of signage at the entrance of the residents' rooms meant that staff and visitors might enter without the necessary personal protective equipment (PPE), increasing the risk of transmitting disease-causing organisms. Resident 4 was admitted with a malfunctioning enterostomy and was dependent on staff for activities of daily living (ADLs). A physician's order indicated that Resident 4 required EBP due to the presence of a jejunostomy tube. However, during an observation, it was noted that there was no signage at the entrance of Resident 4's room to indicate the need for EBP. Similarly, Resident 5, who had severe cognitive impairment and was dependent on staff for ADLs, was ordered to be on EBP due to the presence of a Foley catheter. Again, there was no signage at the entrance of Resident 5's room. Interviews with the Infection Prevention Nurse (IPN) and the Director of Nursing (DON) confirmed that signage should have been present to inform staff, visitors, and vendors of the necessary precautions before entering the rooms. The facility's policy and procedure documents also indicated that clear signage was required to communicate the type of precautions and required PPE. The lack of signage was identified as a deficiency in the facility's infection prevention and control program, as it failed to provide the necessary communication to prevent the spread of infections.
Failure to Implement Care Plan Intervention of Bilateral Floor Mats
Penalty
Summary
The facility failed to implement the care plan intervention of bilateral floor mats for Resident 3, who was identified as high risk for falls. During an observation, it was noted that there was no fall mat on the right side of the bed, and the fall mat on the left side was positioned closest to the roommate's bed. Interviews with RN1 and LVN1 confirmed that fall mats are intended to minimize injury by providing a cushion and that Resident 3 had a doctor's order for fall mats on both sides of the bed. The care plan dated 4/15/2024 also indicated the need for bilateral floor mats for safety precautions. Resident 3 was admitted with diagnoses of muscle weakness, hemiplegia, and dementia, and was dependent on staff for transfers and mobility. A change of condition assessment indicated that Resident 3 was found half dangling from the bed, leading to the doctor's order for bilateral floor mats. The facility's policy, titled Falling Star Program, also required floor mats for residents identified as high risk for falls. Despite these directives, the facility did not ensure the proper placement of the fall mats, potentially putting Resident 3 at risk of injury.
Failure to Implement Infection Control Practices
Penalty
Summary
The facility failed to implement infection prevention and control practices as outlined in their infection control program. Specifically, the facility did not implement Enhanced Barrier Precautions (EBP) as mandated, which required the use of gowns and gloves for specific care activities to limit the spread of infections. Despite being in-serviced on EBP, the facility staff did not adhere to these guidelines, as evidenced by the lack of EBP implementation for residents requiring such precautions. The Infection Preventionist Nurse (IPN) and the Director of Nursing (DON) acknowledged the potential for increased infections due to this failure. The facility also failed to ensure that the Treatment Nurse wore proper personal protective equipment (PPE) during wound treatment for Resident 88. The Treatment Nurse did not wear a disposable gown while performing wound care, despite the resident having an infected left lower leg wound. This was observed during a wound treatment session where the nurse only used gloves and did not follow the facility's infection control policies. Additionally, the facility did not ensure that certified staff used PPE when providing wound treatment for Resident 129. The staff did not wear PPE gowns during high-contact resident care activities, such as wound care, which is required by the facility's Enhanced Barrier Precaution policy. Furthermore, the facility did not follow its own hand hygiene policy, as observed during a medication pass for Resident 16, where the licensed nurse did not wash or sanitize hands before and after taking the resident's blood pressure and measuring oxygen saturation.
Failure to Review Home Medications and Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure that medications brought from home were reviewed by the pharmacist before being administered to residents. Specifically, for two residents, medications stored in two medication carts were not reviewed by the facility's pharmacist. This discrepancy was observed during an inspection and interview with LVNs, who confirmed that the home medications were not sent to the facility's pharmacy for review. The prescription labels on these medications did not match the current physician's orders, leading to potential medication errors and adverse reactions for the residents involved. Additionally, the facility failed to accurately account for and document the administration of Lorazepam, a controlled medication, for another resident. The Controlled Drug Record (CDR) and Medication Administration Record (MAR) showed discrepancies in the number of doses administered versus documented. The LVN responsible admitted to administering doses without proper documentation, which could lead to double dosing and increased risk of side effects. Interviews with the Director of Nursing (DON) and a review of the facility's policies confirmed that home medications must be verified by the facility's pharmacy and that controlled medications require accurate documentation. The lack of adherence to these policies resulted in unsafe medication administration practices, increasing the risk of serious health complications for the residents involved.
Failure to Properly Document and Monitor Lorazepam Use
Penalty
Summary
The facility failed to ensure that lorazepam was used for a medical condition as diagnosed and documented in the resident's clinical record for one resident. The resident was admitted with diagnoses including paranoid schizophrenia, difficulty in walking, muscle weakness, and chronic obstructive pulmonary disease. The facility did not define resident-specific target behaviors regarding the use of lorazepam and failed to monitor the medication for adverse effects and effectiveness. Additionally, the facility did not quantify episodes of constant fidgeting as per the physician's order related to the use of lorazepam. The resident's Medication Administration Record (MAR) indicated zero documented behaviors of constant fidgeting every shift between specific dates. The MAR was also left blank for non-pharmacological interventions for the use of lorazepam. The Licensed Vocational Nurse (LVN) admitted to sometimes forgetting to document the administration of lorazepam immediately after administration and did not document the behavior or reason for administering the PRN medication in the nursing progress notes. The LVN also stated that non-pharmacological interventions were not tried prior to administering lorazepam. The Director of Nursing (DON) confirmed that the resident's Controlled Drug Record (CDR) indicated the resident was administered 12 doses of lorazepam, but only 4 doses were documented on the MAR. The DON stated this discrepancy could result in a medication error and negatively affect the resident. The facility's policy and procedure for psychotropic use and medication administration were not followed, leading to the failure to document specific behaviors, adverse reactions, and the effectiveness of the medication, which could have contributed to the resident's fall.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication pass for four of five sampled residents. For Resident 621, the facility did not administer hydroxychloroquine and potassium chloride extended release (ER) in accordance with the manufacturer's specifications and the facility's policy. Additionally, Resident 621's physician order for aspirin was not administered as prescribed. The Licensed Vocational Nurse (LVN) 6 crushed medications that should not be crushed and administered them to Resident 621, which was against the facility's policy and the medication's instructions. This error was repeated multiple times, and the nurse did not realize the mistake until it was pointed out by the surveyor. The nurse admitted to not checking the medication cards properly and acknowledged the potential health risks involved in crushing non-crushable medications. Other staff members also confirmed the importance of not crushing certain medications and the proper procedures to follow, which were not adhered to in this case. Resident 10 was not administered Metformin within the scheduled time frame as per the facility's policy. The medication was given almost two hours late without any documentation or notification to the physician. The nurse responsible admitted to the delay and acknowledged that there was no valid reason for the late administration. The Director of Nursing (DON) confirmed that Metformin should be administered with food and that any significant delay should be reported to the physician. Resident 16 was administered a lower dose of docusate sodium than prescribed and was not identified using at least two identifiers before medication administration. The nurse responsible admitted to the mistake and acknowledged that the resident was not wearing an identification band. The DON confirmed that proper identification procedures were not followed. Additionally, Resident 53's medications, which required shaking before administration, were not shaken, leading to potential underdosing. The nurse responsible admitted to not following the manufacturer's instructions, and the DON confirmed the importance of shaking medications to ensure proper dosing.
Deficient Pureed Food Preparation
Penalty
Summary
The facility failed to prepare food by methods that conserved texture and appearance for 23 residents receiving a pureed diet. During an initial facility tour, complaints about the flavor of the food were identified. Observations during lunch service revealed that the pureed lasagna was dry, lumpy, and contained large pieces of pasta, which required chewing before swallowing. This was confirmed by Cook 1, who stated that the lasagna was pureed using a blender with some broth, but the resulting texture was not smooth. A test tray further confirmed the presence of chunky pieces that required chewing. The Dietary Supervisor and Registered Dietitian both acknowledged that the pureed lasagna did not meet the required smooth consistency and posed a choking risk for residents with swallowing difficulties. The facility's menu and policy indicated that pureed food should be smooth and moist, able to hold its shape, and not require chewing. The Registered Dietitian also verified with the facility's speech therapist that pureed products should not require chewing before swallowing. The facility's policies and procedures were reviewed, confirming that the pureed diet should be of a smooth and moist consistency, in compliance with national guidelines and physicians' orders.
Deficient Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. Six plastic bags of packed lunch with meat sandwiches for residents were stored in the refrigerator with use-by dates exceeding the storage period for previously prepared sandwiches. Additionally, a medium-sized container of tomato sauce and cooked green beans were stored past their use-by dates. There were also four ham and cheese sandwiches stored without any date, and a liquid egg carton with an open date exceeding the manufacturer's use-by date. A large bowl of previously prepared whipped cream was stored uncovered, and ready-to-eat deli meats were stored in a dirty container with juices and small pieces from the deli meats. The Dietary Supervisor acknowledged these issues and stated that the items should be discarded and that all food should be labeled, dated, and covered during storage to prevent cross-contamination and ensure food safety. The dry storage area was not maintained in a clean manner, with food debris on top of bulk food containers and a torn bin liner inside the bin holding flour, causing flour to spill inside the bin. Rusted metal parts were also observed inside the bin. The Dietary Supervisor stated that the dry food storage area should always be clean to prevent pests and that the liners storing bulk food should be intact. The facility's policy and procedure indicated that storerooms should always be clean and that dry bulk food should be stored in seamless metal or plastic containers with tight covers or in bins that are easily sanitized. Previously cooked ground beef with a preparation date of 3/27/2024 and a use-by date of 3/29/2024 was used to prepare lunch on 4/1/2024. The ground beef was not monitored for a safe cool-down process, and the cooking and cooling of the ground beef were not documented. The Dietary Aide and Cook were unaware of who cooked the ground beef and did not check the dates, leading to the use of potentially unsafe food. The facility's policy and procedure indicated that hot foods to be refrigerated should be placed in shallow pans to permit rapid cooling. The Dietary Supervisor acknowledged the mistake and stated that the ground beef cooked on 3/27/2024 was not safe because it was not known if it was cooled and stored in a safe way.
Failure to Inform Resident of Medication Administration
Penalty
Summary
The facility failed to keep a resident informed and did not ensure a resident exercised his right to choose by not informing Resident 74 of the medications being administered prior to administration. During an observation, an LVN was seen giving Resident 74 a medicine cup containing pills without explaining what medications were in the cup. Resident 74, who had fluctuating capacity to understand and make decisions, stated he did not know what medication he had just swallowed and expressed a desire to be informed about the medications he was taking. The LVN admitted to not following the facility's policy of informing residents about their medications, acknowledging it was a violation of the resident's rights. Interviews with the Director of Staff Development and the Director of Nursing confirmed that it was the facility's policy and expectation for licensed nurses to explain the medications to residents prior to administration. The facility's Policy and Procedure on Medication Administration also indicated that licensed nurses must explain to residents the type of medication being administered and the procedure. The failure to inform Resident 74 of his medications violated his right to be informed and to participate in his care, as outlined in the facility's policies and procedures.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure respect and dignity for Resident 134 by serving meals with disposable plastic utensils without informing the resident of the reason. Resident 134, who had diagnoses including fibromyalgia, depression, and paraplegia, had intact cognitive skills and was capable of making decisions. Despite this, there were no physician orders or care plans addressing the need for plastic utensils, and the resident was not informed why she was receiving them, leading to feelings of distress and indignity. During observations and interviews, it was revealed that Resident 134 had been receiving plastic utensils since January 2024 due to previously verbalized suicidal ideations. However, there was no documentation in the care plans, physician orders, or nursing notes to support this intervention. Staff members, including CNAs, LVNs, and the Dietary Supervisor, were unaware of the reason for the use of plastic utensils and did not communicate this to the resident. The Director of Nursing confirmed that plastic utensils were used as an intervention for residents with suicidal ideations but acknowledged that once the resident was no longer in danger, the use of plastic utensils should have ceased. The facility's policy on dignity emphasized the importance of promoting quality of life, respect, and individuality, and prohibited demeaning practices. The failure to discontinue the use of plastic utensils and inform the resident of the reason violated this policy and compromised the resident's dignity and well-being.
Violation of Resident's Right to Privacy
Penalty
Summary
The facility failed to respect a resident's right to personal privacy by allowing the case manager to open Resident 90's mail without permission. Resident 90, who had intact cognitive skills and the capacity to make decisions, reported that her mail was opened multiple times by the case manager despite her requests for it to remain unopened. The case manager admitted to opening the mail to verify medical appointments and acknowledged that she did not have permission to do so. This action made Resident 90 feel violated and upset, as she had to repeatedly ask the case manager to stop opening her mail. The Director of Nursing confirmed that the facility's policy requires all mail to be delivered unopened unless otherwise indicated by the attending physician and documented in the resident's medical record. The facility's policy and procedure on mail, dated January 2024, also stated that staff members should not open mail unless requested by the resident. The case manager's actions were in direct violation of this policy, as well as the resident's right to privacy, as outlined in the facility's guidelines.
Failure to Develop Care Plan for Resident with Suicidal Ideations
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident with suicidal ideations. The resident, who had diagnoses including fibromyalgia, depression, and paraplegia, expressed suicidal thoughts due to feeling anxious and sad when her family did not visit her during the holidays. Despite these expressions, there was no care plan addressing her suicidal ideations, which was confirmed during interviews with staff and a review of the resident's records. The resident's Minimum Data Set (MDS) indicated that her cognitive skills for daily decision-making were intact, and she required assistance with personal hygiene, toileting, and eating. The resident's History and Physical (H&P) also confirmed her capacity to understand and make decisions. However, a Change of Condition (COC) assessment noted that the resident verbalized wanting to kill herself, and she was monitored every 15 minutes for a few days. Despite these measures, the care plan did not reflect her suicidal ideations. Interviews with various staff members, including the Dietary Supervisor, Licensed Vocational Nurse (LVN), and the Director of Nursing (DON), revealed that the lack of a care plan for the resident's suicidal ideations was a significant oversight. The DON emphasized the importance of having a care plan to provide proper interventions and prevent residents from hurting themselves. The facility's Policy and Procedure (P&P) also indicated that care plans should include measurable objectives and timetables to meet the resident's needs, which was not adhered to in this case.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to maintain appropriate grooming and personal hygiene for two residents, leading to dirty and untrimmed nails. Resident 88, who has diagnoses including cellulitis, type 2 diabetes, and cerebral infarction, was observed multiple times with a black substance under his fingernails. Despite being able to understand and make decisions, Resident 88 stated that no one had assisted him with nail care. Staff members, including a Psychiatric Assistant, Licensed Vocational Nurse, and Registered Nurse, acknowledged the issue and highlighted the potential risks of infection and cross-contamination due to the dirty fingernails. The Director of Nursing confirmed that nail care should be assessed daily and that Resident 88's nails should have been cleaned and trimmed by the staff if he was unable to do so himself. Similarly, Resident 222, who has diagnoses including COPD, schizophrenia, depression, dementia, and muscle weakness, was found with long toenails and a brown substance underneath them. Resident 222 expressed that he could not remember the last time his toenails were cleaned or cut and stated that he would like staff assistance for this. A Certified Nursing Assistant confirmed the condition of Resident 222's toenails and acknowledged that it was their responsibility to clean and trim the nails. However, there was no documentation to show that the toenails' status was reported to the charge nurse or that a podiatrist visit was scheduled. The Licensed Vocational Nurse and Social Services staff also confirmed that the toenails should have been assessed and reported for further care. The facility's policy and procedure on Activities of Daily Living (ADLs) indicated that assistance should be provided to residents for personal hygiene, including nail care. However, the observations and interviews revealed that the staff failed to adhere to these guidelines, resulting in the residents having dirty and untrimmed nails, which posed a risk of infection and negatively impacted their quality of life and self-esteem.
Failure to Conduct Post-Fall Assessment and IDT Meeting
Penalty
Summary
The facility failed to assess and identify the potential hazard and resident's risk factors for falls for one of three sampled residents by not completing a Post-Fall Assessment and conducting an Interdisciplinary Team (IDT) meeting after the resident had an unwitnessed fall. The resident, who had a history of cerebral infarction, metabolic encephalopathy, and schizophrenia, was found on his knees on the floor of his room. Despite the resident's severe cognitive impairment and use of a wheelchair for mobility, the necessary post-fall assessments were not conducted, and the IDT meeting was not held to determine the cause of the fall and implement preventive measures. This failure increased the potential for future falls and injury for the resident. Interviews with the Licensed Vocational Nurse (LVN), Assistant Director of Nursing (ADON), and Director of Nursing (DON) revealed that the facility's protocol required a post-fall Morse Fall Scale assessment and an IDT meeting to be conducted after any fall. The LVN admitted to forgetting to complete the post-fall assessment, and the ADON was not informed of the fall, resulting in the IDT meeting not being conducted. The DON confirmed that the lack of a post-fall assessment and IDT meeting prevented the identification of additional risk factors and the implementation of appropriate interventions to prevent further falls. The facility's policy and procedure on Accident Management, reviewed in January 2024, stated that residents should be assessed for fall risk factors upon admission, quarterly, after a change of condition, and annually. The policy also required the IDT to conduct a post-fall meeting to review risk factors and recommend further interventions. The failure to follow these procedures for the resident who experienced an unwitnessed fall on March 31, 2024, resulted in an increased risk of future falls and injury for the resident.
Failure to Administer Medications According to Manufacturer's Specifications
Penalty
Summary
The facility failed to ensure that Resident 621 was free from significant medication errors when Potassium Chloride ER, a medication that should not be crushed, was administered in a crushed form mixed with other medications. This was not in accordance with the manufacturer's specifications and the facility's policy and procedure on medication administration. The error was observed during a survey when LVN 6 was about to administer the crushed mixture to Resident 621, who has a history of dysphagia and difficulty swallowing medications. Resident 621's medical records indicated that the resident was not capable of giving informed consent and had a legal guardian. The resident's medication administration record showed that Potassium Chloride ER was crushed and administered along with other medications on multiple occasions. LVN 6 admitted to not realizing that the medication should not be crushed and acknowledged the potential health risks associated with this error. Other LVNs interviewed confirmed that they were aware of the guidelines against crushing certain medications, including Potassium Chloride ER. The Director of Nursing (DON) stated that nurses were supposed to check the order, electronic medical record, medication card, and medication bottle for special instructions before administering medications. The facility had a list of medications not to be crushed, and nurses were instructed to consult this list and ask supervisors if unsure. The facility's policy and procedure emphasized that medications should be administered as prescribed and in accordance with manufacturers' specifications, and that long-acting or enteric-coated dosage forms should generally not be crushed.
Failure to Serve Food According to Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure tortillas served during lunch were in accordance with a physician's order for a mechanical soft diet for one resident. This resident, who had missing teeth and was on a mechanically altered diet, was observed multiple times struggling to chew the tortillas served with her meals. Despite the resident's difficulty, the tortillas continued to be served in a manner that was not soft enough for her to chew easily, leading her to only eat the filling and leave the tortillas uneaten. Interviews with the resident revealed that she found the tortillas difficult to chew due to her lack of upper teeth. The Dietary Supervisor acknowledged that the preparation method could result in the tortillas becoming harder over time, making them difficult for the resident to chew. Both the Licensed Vocational Nurse and the Registered Nurse confirmed that serving food that was too hard for the resident to chew placed her at risk of choking and aspiration. The Director of Nursing also confirmed that the mechanical soft diet should ensure food is soft enough to chew without difficulty. The facility's policy indicated that the mechanical soft diet is designed for residents with chewing or swallowing limitations, and the food should be modified to a soft consistency. Despite this policy, the resident continued to receive tortillas that were not adequately softened, posing a risk to her safety and nutritional intake.
Failure to Provide Appropriate Call Light System for Resident
Penalty
Summary
The facility failed to assess and provide an appropriate call light system for Resident 124, who had significant physical and cognitive impairments. Resident 124, who was admitted with diagnoses including respiratory failure and blindness in one eye, had severe cognitive impairment and was dependent on staff for various activities of daily living. The resident also had functional limitations in both upper and lower extremities and left-sided weakness due to a stroke. Despite these limitations, the resident was provided with a standard call light system that they were unable to activate due to weakness in their hands and fingers. This was observed during an inspection where the resident attempted but failed to activate the call light, and the CNA confirmed the resident's inability to use the call light but had not taken any action to address this issue. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that the facility's policy required providing a call light system that residents could use to communicate their needs. Both the DSD and DON acknowledged that a touch pad call light system would have been more appropriate for Resident 124, given their physical limitations. The facility's policy on Accommodation of Needs also indicated that residents' individual needs and preferences, including the need for adaptive devices, should be evaluated upon admission and reviewed on an ongoing basis. However, this was not done for Resident 124, leading to the deficiency in providing an appropriate call light system.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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