Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fidelity Health Care during CMS and state inspections, most recent first.
A resident with osteoarthritis, DM, weakness, and coordination issues had a cluttered bedside area that blocked access to the bed. The resident’s care plan noted non-compliance with safety measures due to many personal items around the bed, and the ITC record showed the resident refused staff permission to clean or remove belongings even after risks were explained. During observation, staff found items on the floor, a broken lamp, cords, papers, and food items around the bed; a CNA stated the clutter was a tripping hazard and could delay emergency care.
Unsafe and Unsanitary Shared Resident Room and Bathroom: Surveyors observed a shared resident room and bathroom with dark splatter marks on the ceiling and walls, unpainted drywall, damaged wood and door surfaces, a hole in the bathroom door, and dark black substance in the toilet caulking that looked like mold. A HK, CNA, and RN all stated the bathroom was dirty or needed repairs, and one resident said the room had never been painted and the bathroom was disgusting and avoided if possible.
Call lights were not kept within reach for two residents with significant cognitive and functional impairment. One resident with osteoporosis, osteoarthritis, and DM was observed in bed with the call light placed behind the headboard, and staff stated the resident was confused and could not use the push-button light. Another resident with weakness, overactive bladder, and psychosis was observed in bed and later in a wheelchair with the call light left on an empty bed; staff stated the resident could not reach it and that it should have been placed with the resident.
A facility failed to code MDS assessments accurately for three residents. One resident’s MDS did not reflect a recent fall, another resident’s MDS omitted a psychotic disorder and did not capture documented behaviors such as yelling, striking out, and hitting staff, and a third resident’s MDS incorrectly listed discharge back to an acute hospital instead of discharge home AMA. The MDSC and DON acknowledged the assessments were inaccurate and that MDS coding should reflect the resident’s condition and support accurate reporting to CMS.
Failure to Rotate Insulin Injection Sites: The DON and record review showed that insulin injections were repeatedly given at the same sites for three residents with DM who had active insulin orders. One resident had intact cognition and legal blindness, while two residents had severely impaired cognition; all received insulin before meals and at bedtime, and one also received basal insulin. The facility policy stated insulin sites should be rotated according to accepted nursing practice.
Unsafe environment and smoking/hemodialysis safety failures: A resident on renal dialysis with a Perma catheter did not have a dialysis E-kit at bedside, a shaver was left unattended in a restroom, and a resident who required supervised smoking had a lighter in possession. Staff and the DON acknowledged the items were not managed according to facility policy, and the residents’ records showed the residents had conditions and care plans tied to these safety needs.
Inaccurate Weight Documentation in Paper Chart and EMR: Two residents had mismatched weights between the paper chart and EMR. One resident with anemia, GERD, and diverticulosis had weekly weights documented as 99 lbs. and then 97 lbs. in the chart, while the EMR showed 113 lbs. each time. Another resident with muscle wasting, atrophy, and dementia had charted weights of 135 to 136 lbs., while the EMR repeatedly showed 132 lbs. Staff and the DON stated historical weights were being copied into the EMR incorrectly.
Failure to Use Required PPE During EBP Care: Two residents on EBP were observed receiving high-contact care without the required gown. An MDS C touched a resident's GT site while wearing gloves only, and an RNA transferred another resident from a wheelchair to bed while wearing gloves only. Both residents had care plans and OSRs indicating EBP for wounds or a feeding tube, and facility policy required gowns and gloves during high-contact care activities such as transfers and device care.
A resident with severely impaired cognition and an active order for routine podiatry care refused treatment, but the care plan did not address the refusal or related podiatry needs. Surveyors observed long toenails on both feet, and CNA and RN staff confirmed the nails were long. Review of the record showed no care plan for podiatry care or refusal, and the DON acknowledged the resident had a risk for infection with long toenails.
A resident with dementia, major depressive disorder, and schizophrenia, assessed as high fall risk with impaired cognition and needing supervision or assistance for transfers and walking, was care planned for close monitoring of location and a safe environment. Despite this, the resident was observed by a family member walking alone in a hallway without staff present, and a CNA did not immediately intervene when notified. Staff interviews revealed that monitoring was based on intermittent checks rather than continuous observation, that one CNA was covering another’s break and could not see all residents, and that staff were not yet fully familiar with the new resident’s needs, contrary to the facility’s fall prevention policy requiring close monitoring of at-risk residents.
A resident with chronic pain syndrome, intact cognition, and independence in daily activities was transferred to a general acute care hospital for pain based on a physician order and documented in progress notes. However, the nurse responsible for the transfer did not complete a Notice of Proposed Transfer/Discharge (NPTD), and the LTC Ombudsman was not notified. During interviews, an LVN, RN, and the DON all acknowledged that facility practice and written policy required completion of an NPTD to inform the resident of the transfer destination and reason, and that this notice should be placed in the medical record and provided to the resident and, if known, a family member or representative.
Two residents with intact cognition and complex medical histories were involved in ongoing verbal and emotional abuse, with one resident repeatedly using derogatory language toward the other. Despite staff awareness and social services intervention, the situation escalated to a physical altercation, resulting in one resident being choked and punched, and sustaining a neck injury. The facility failed to prevent or adequately address the abusive behaviors, leading to a deficiency in protecting residents from abuse.
Two residents with severe cognitive and physical impairments were assisted with eating by CNAs who stood over them rather than sitting at eye level, contrary to facility policy and staff training. This practice failed to honor the residents' right to dignity and proper engagement during mealtime.
Surveyors found that kitchen staff failed to label opened food items with the date opened, did not use pasteurized eggs as required for certain dishes, stored clean dishware and kitchenware uncovered and face up, and did not consistently wear hair restraints in food preparation and dishwashing areas. These actions were not in accordance with the facility's policies and professional standards for food safety.
Staff did not change a resident's nasal cannula for oxygen therapy weekly as required, and personal toiletry items for multiple residents sharing a restroom were found unlabeled and improperly stored, contrary to infection control policies. These lapses were confirmed by staff interviews and policy review.
A resident with severe cognitive impairment and a high risk for falls was found with their call light inaccessible, as it was stuck behind personal belongings. Staff confirmed the resident could not reach the call light, despite care plan and facility policy requiring it to be within reach to ensure timely assistance.
A resident with COPD and diabetes was admitted without a properly completed Advance Directive Acknowledgement (ADA) form. The ADA form lacked documentation of whether the resident had executed an advance directive, was missing a date, and did not have the facility's signature, contrary to facility policy requiring completion within seven days of admission.
A resident with significant care needs was admitted under hospice services, but the facility did not assign a staff member to coordinate with hospice representatives. As a result, scheduled visits by a CHHA could not be verified, and the DON confirmed there was no policy or procedure for assigning responsibility for hospice coordination, leading to uncertainty about whether the resident received necessary hospice care.
A resident with moderately impaired cognition and multiple diagnoses was found to have a bedside electric fan with dust and lint accumulation. An LVN confirmed the fan's unclean condition, and the DON stated that housekeeping is responsible for keeping equipment clean to prevent respiratory issues. Facility policy requires regular housekeeping and maintenance of resident equipment.
The facility failed to follow its policies for screening potential employees for abuse history. The Director of Staff Development did not obtain adequate reference checks for four CNAs, often relying on personal knowledge instead of contacting previous employers. This practice did not comply with the facility's policy, which required at least two reference checks to uncover any past criminal prosecutions or allegations of abuse.
A resident with cognitive impairment was verbally and physically abused by another resident with a history of aggressive behavior. The incident occurred when the assigned CNA left the aggressive resident unattended, contrary to the facility's one-to-one monitoring policy. This lapse in supervision allowed the aggressive resident to scratch and yell at the other resident, resulting in an open cut on the hand.
A facility failed to report an allegation of abuse within the required two-hour timeframe. A resident reported being hit by another resident, but the Social Services Assistant did not inform anyone about the allegation, violating the facility's policy. The reporting failure involved a cognitively intact resident and another resident with schizophrenia. Staff interviews confirmed the importance of timely reporting to prevent further abuse.
The facility failed to submit the Payroll Based Journal (PBJ) staffing data report for the first quarter of 2023, resulting in a one-star staffing rating. Interviews revealed no records of proof indicating the previous Business Office Manager submitted the PBJ data, and the Administrator confirmed the absence of official records. Handwritten notes were found but were not considered official.
The facility failed to ensure call lights were within reach for two residents, leading to potential delays in care and increased fall risk. One resident's bathroom lacked a call light cord, while another's call light was stuck behind a roommate's walker. Both residents had high fall risk and required call lights within reach as per their care plans and facility policy.
The facility failed to supervise two residents adequately, leading to potential safety hazards. One resident with a history of wandering was not provided specific interventions, while another high-risk resident was left unattended multiple times despite requiring continuous one-to-one monitoring.
The facility failed to administer Depakote ER as ordered by splitting the tablet, and did not follow its policy for medication destruction by having an Activity Assistant, supervised by only one licensed nurse, dispose of medications.
The facility failed to monitor and provide a Gradual Dose Reduction (GDR) for two residents, leading to the potential use of unnecessary psychotropic medications. For one resident, a GDR was not completed for Trazodone, and no clinical rationale was documented. For another resident, behaviors related to the use of Zyprexa were not monitored during specific night shifts, contrary to the care plan and facility policy.
The facility failed to discard six glasses of expired milk found in the kitchen refrigerator. The Dietary Supervisor acknowledged that the milk was outdated and should have been removed to prevent food-borne illnesses. The facility's policy indicated that poured beverages should be labeled, dated, and discarded at the end of the day.
The facility failed to follow infection control policies by not ensuring a CNA wore PPE before entering a contact isolation room for a resident with MRSA and by allowing food to be stored in the medication storage room. The CNA entered the resident's room without PPE, and a box of doughnuts was found in the medication room, both actions contrary to the facility's policies.
A resident with COPD, epilepsy, and dementia did not have the privacy curtain closed while a Licensed Vocational Nurse checked the gastrostomy tube site, exposing the resident's abdominal area. This action violated the facility's policy on providing privacy during ADLs and the resident's care plan. The Director of Nursing confirmed the need for the privacy curtain to be closed to maintain the resident's dignity and privacy.
The facility failed to develop a care plan for a resident with dementia, schizophrenia, and anxiety who exhibited wandering behavior by entering other residents' rooms. Despite multiple reports and observations, no care plan addressed the resident's wandering, contrary to facility policy.
The facility failed to conduct an IDT care planning conference for a resident with type 2 diabetes mellitus and anemia within the required timeframe. The DON confirmed that the conference was missed, and an empty form was found in the resident's medical record. This failure had the potential to delay appropriate care and treatment for the resident.
The facility failed to monitor a resident with Parkinson's disease and osteoarthritis during mealtime as required by the care plan, leading to food spillage and potential nutritional deficiencies. Despite observed increased hand tremors, there were no records of assessments or notifications to the medical doctor or occupational therapist.
The facility failed to implement the intervention on a resident's care plan for turning and repositioning every 2 hours, despite the resident's risk for skin breakdown due to impaired mobility and incontinence. Observations showed the resident remained in the same position for extended periods, contrary to the care plan and Resident Positioning Log.
A resident's nasal cannula tubing was observed touching a trash bin, contrary to the facility's Infection Control Policy: Oxygen Use. The resident had COPD and heart failure, and the observation was confirmed by an LVN and the DON, who both acknowledged the risk of infection and cross-contamination.
Cluttered Bedside Area Blocked Access to Resident’s Bed
Penalty
Summary
The facility failed to ensure Resident 4’s environment was safe, clean, comfortable, and homelike when clutter around the resident’s bed blocked access to the bed. Resident 4 was initially admitted to the facility and later readmitted with diagnoses including osteoarthritis of both hips and the right knee, type 2 DM, weakness, and other lack of coordination. The resident’s H&P indicated the resident was self-responsible and had the capacity to understand and make decisions, and the MDS indicated intact cognition with partial/moderate assistance needed for several ADLs and substantial/maximal assistance needed for bathing. Resident 4’s care plan identified non-compliance with safety measures related to having many personal items around the bed. The interdisciplinary team conference record stated the meeting was held because Resident 4 refused staff in general to touch and clean up belongings. Social Services and housekeeping went to the room and asked permission to clean and remove items no longer needed, but Resident 4 refused even after the risks and benefits were explained. The record also stated Resident 4 was told that paramedics would not be able to move freely in the room during an emergency because of the clutter, but the resident continued to refuse staff to clean up items around the bed. During observation, the room contained clutter surrounding the bed, including items on the floor on the right side of the bed, a broken lamp, a waste can, paper/mail under the bed, a partially blocked pathway, a 4-plug extension cord with multiple cords and papers/mail nearby, and multiple food items on the bedside table, including perishable items. CNA 4 stated it was very difficult to get past the items on the floor to reach the right side of the bed, that the items were a tripping hazard and unsafe, and that emergency care could be delayed because the items would have to be moved first. Resident 4 stated the resident had asked staff to help clean the room because standing for long periods was difficult, but staff said they would help and never came.
Unsafe and Unsanitary Shared Resident Room and Bathroom
Penalty
Summary
The facility failed to maintain a safe and sanitary resident room and bathroom for three residents who shared the space. During observation of the room and bathroom, surveyors found dark colored splattered marks on the ceiling near one resident’s bed, two large unpainted drywall spots on the adjacent wall, a wood board behind the headboard with scraped, dented, and unpainted areas, and multiple dark splattered marks on the ceiling and adjacent wall in the corner near the bathroom door. In the bathroom, surveyors observed unplastered wall areas, an unknown dark substance splattered on the inside bathroom door, a 1-inch by 4-inch rectangular hole in the door, and a chipped, dented, and dirty door frame. Surveyors also observed dark black substance in scattered areas of the caulking at the bottom of the toilet that looked like mold. Housekeeper 1 stated the bathroom needed repairs and did not have a good appearance for the residents who used it. CNA 4 stated the bathroom was dirty, housekeeping and maintenance were responsible for keeping it in good condition, and housekeeping or maintenance were notified for cleaning or repairs. CNA 4 also stated there was no maintenance logbook and that nothing had been reported about the bathroom. RN 2 stated the bathroom was not clean and posed a health risk to the residents who used it. Resident 4 stated the room had always been the same and had never been painted, that the facility had painted other areas but not the residents’ room, and that the bathroom was disgusting and avoided if possible. Resident 4 also stated the spots on the ceiling were from coffee thrown by another resident some time ago and had not been cleaned. The facility’s Maintenance Policy stated the environment was to be safe, clean, functional, and well-maintained, with timely response to repair and maintenance requests.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure call lights were within reach and appropriate to the residents' physical abilities for two residents. Resident 13 was admitted with diagnoses including osteoporosis, osteoarthritis, and DM. The MDS dated 3/19/2026 indicated Resident 13 had severely impaired cognition and required partial/moderate assistance with eating and oral hygiene, and substantial/maximal assistance with toileting, showering, upper/lower body dressing, and personal hygiene. During observation on 6/3/2026, Resident 13 was lying in bed with the push-button call light placed at the back of the headboard, and CNA 2 stated the resident was confused, could not reach the call light, and did not know how to use it. CNA 2 stated call lights should be placed next to the resident, and the DON stated a sensor pad call light was more appropriate for Resident 13's physical and functional ability. Resident 56 was admitted with diagnoses including weakness, overactive bladder, and psychosis. The H&P dated 12/6/2025 indicated Resident 56 did not have the capacity to understand and make decisions due to psychosis. The care plan dated 12/8/2025 indicated Resident 56 required assistance with ADLs due to muscular weakness and included an intervention for nursing staff to keep the call light within reach. The MDS indicated Resident 56 had severely impaired cognition and required assistance with eating, transferring, oral hygiene, toileting hygiene, personal hygiene, toilet transferring, and bathing. During observation on 6/2/2026, Resident 56 was in bed and later in a wheelchair, and in both observations the call light was not within reach and was found on Bed A. Resident 56 stated the call light could not be reached. CNA 1 reviewed the pictures and stated the call light was not within reach, should be placed on the bed when in bed, and should be with the resident in the wheelchair for safety. CNA 1 also stated residents use the call light to call for help and that everyone in the facility should ensure it was within Resident 56's reach, while the DON stated the resident was at risk of falling and could not call for help when needed if the call light was not within reach.
Inaccurate MDS Coding for Fall, Behaviors, and Discharge Destination
Penalty
Summary
The facility failed to implement its Resident Assessment Instrument and MDS policies by coding inaccurate resident assessments for three sampled residents. The report states that the MDS assessments were not coded accurately for a resident’s fall, another resident’s psychotic disorder and behaviors, and a third resident’s discharge destination. The facility’s own policies required MDS assessments to be accurate and to reflect the resident’s status during the assessment reference period. For one resident, the record showed a fall on 4/10/2026, including an incident note, change in condition evaluation, and later H&P documenting a recent fall. RN 1 stated the resident was a fall risk with an unsteady gait and had last fallen in the facility on that date. However, the MDS dated after the event indicated the resident did not have a fall in the last month or in the prior two to six months before admission or reentry. The MDSD and DON both acknowledged the resident had a recent fall and that the MDS was inaccurate. For another resident, the record included diagnoses of psychosis and a psychiatric progress note identifying a psychotic disorder. The resident’s social service note also documented screaming without reason, striking out, and hitting staff, and the MAR showed repeated behaviors of striking out, yelling, and hitting staff before the MDS completion date. The MDSC stated the MDS did not indicate a psychotic disorder and did not correctly code the resident’s physical behavior symptoms directed toward others or other behavior symptoms not directed toward others. The MDSC stated the assessment was not accurate and should have reflected the resident’s condition. For the third resident, the record showed the resident was discharged home against medical advice, as documented in the physician order and discharge summary. The MDS, however, coded the discharge destination as a return to the acute hospital. The MDSC stated this was incorrect and confirmed the resident was discharged home. The DON stated the MDS should be coded correctly to reflect the resident’s overall current health condition and to report accurate information to CMS.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to meet professional standards of care by not rotating insulin injection sites for three residents who had active insulin orders. Resident 3 was admitted with type 2 DM and legal blindness, had intact cognition on MDS, and received HumuLIN R insulin before meals and at bedtime. Review of the MAR with the DON showed the insulin was administered at the same injection sites on multiple dates in May and June 2026, and the DON stated the site should have been rotated each time. Resident 8 was admitted with type 2 DM and HTN, had severely impaired cognition, and had an active order for HumuLIN R insulin before meals and at bedtime. Review of the MAR with the DON showed the insulin was given at the same injection sites on multiple dates in late May and early June 2026 without rotation. The DON stated the licensed nurse did not rotate the insulin injection site and should have. Resident 53 had diagnoses including type 2 DM and HTN, could not make decisions, had severely impaired cognition, and received both insulin Aspart before meals and at bedtime and insulin Glargine at bedtime. Review of the MAR with the DON showed insulin Aspart and insulin Glargine were administered at the same injection sites on multiple dates in May and June 2026 without rotation. The facility's Insulin Administration policy stated insulin should be administered in accordance with accepted nursing standards and that the licensed nurse should rotate insulin injection sites according to accepted nursing practice.
Unsafe Environment and Smoking/Hemodialysis Safety Failures
Penalty
Summary
The facility failed to maintain a safe environment for two sampled residents by not following its own policies related to hemodialysis care, environmental safety, and smoking safety. Resident 3 was admitted with acute kidney failure, dependence on renal dialysis, and legal blindness, and had a Perma catheter in the left upper chest. The resident’s care plan identified a risk of bleeding related to the catheter, but during observation the resident did not have a dialysis emergency kit at bedside. The LVN stated the kit was important for emergencies such as active bleeding at the catheter site, and the DON stated the kit should have been available and that it had not been placed in the bedside drawer. The facility also left a blue shaver unattended on top of the hand soap dispenser in Room A’s restroom during multiple observations. The shaver remained there across several checks and was still present when the LVN observed it. The LVN stated the shaver should never be in a resident’s restroom and should be disposed of in the sharps container to prevent injury. The DON stated the shaver should not be left unattended in the restroom and identified staff as responsible for assisting residents with shaving. Resident 28, who had COPD, hyperlipidemia, and hypertension, had a care plan and smoking safety assessment indicating smoking was to occur only with supervision and that staff were to monitor the resident’s whereabouts during smoking time. During observation, the resident stated having smoked two weeks earlier and kept a lighter in the left pocket. RN 1 stated lighters and smoking paraphernalia should not be in the resident’s possession and should be kept in the Activity Department for safety. The AD and DON both stated residents were not allowed to keep lighters in their possession, and the facility’s smoking policy stated cigarettes and lighters were to be kept in the Activities office or nursing stations.
Inaccurate Weight Documentation in Paper Chart and EMR
Penalty
Summary
The facility failed to ensure residents' weights were documented accurately in the medical record and EMR for two residents. One resident had diagnoses including anemia, GERD, and diverticulosis, was on a pureed and therapeutic diet, and had care plan interventions to monitor weight and report significant changes. The resident's paper chart weekly weights showed 99 lbs. on 5/8/2026 and 97 lbs. on 5/15/2026, 5/23/2026, and 5/29/2026, while the EMR weights from 2/19/2026 to 5/14/2026 showed 113 lbs. for each measurement. Another resident had diagnoses including muscle wasting and atrophy and dementia with mood disturbance, lacked capacity to understand and make decisions, and was identified as at risk for malnutrition, weight variance, and dehydration. The resident had an order for weekly weights for four weeks and then monthly, and the care plan directed staff to monitor weight weekly and report continued weight loss to the physician and dietitian promptly. The paper medical record weekly weights showed 135 lbs. on 4/17/2026 and 136 lbs. on 4/24/2026, 5/1/2026, and 5/8/2026, while the EMR weights from 1/8/2026 to 5/25/2026 showed 132 lbs. during each measurement. During interviews, an LVN stated the correct weights were the ones documented in the paper chart for one resident and that the EMR weights were incorrectly documented. The DON stated nursing staff were incorrectly copying and entering historical weights into the EMR for both residents and that the incorrect weights could cause confusion and problems in managing residents' weights. The facility's documentation policy required changes in residents' medical or mental condition and all services provided to be documented in the medical record, and the nutrition and hydration policy required staff to monitor and document weight monitoring.
Failure to Use Required PPE During EBP Care
Penalty
Summary
The facility failed to provide residents on Enhanced Barrier Precaution (EBP) a safe and sanitary environment to help prevent the development and transmission of communicable diseases for two sampled residents. Resident 13 was admitted with diagnoses including gastrostomy, history of UTI, and DM. The MDS showed severely impaired cognition, partial/moderate assistance with eating and oral hygiene, substantial/maximal assistance with toileting, showering, dressing, and personal hygiene, and feeding tube use for nutrition. The care plan identified Resident 13 as at risk for MDRO related to GT feeding and directed staff to use EBP with gloves, gown, and hand hygiene during high-contact care activities, including device care. During a concurrent observation in Resident 13's room, the MDS C checked and touched the resident's G-tube catheter and site while wearing gloves only and not a gown. The MDS C stated a gown and gloves were needed before checking and touching the GT catheter and site to prevent the spread of infection. Resident 13's OSR also indicated the resident was on EBP related to GT feeding and pressure injury. Resident 36 was admitted with diagnoses including an open wound on the right thigh, history of UTI, and a stage 3 pressure ulcer on the upper left back. The care plan identified a right thigh wound and stage 3 pressure injury on the left deltoid and directed EBP during high-contact resident care activity. During a concurrent observation in Resident 36's room, RNA 1 transferred the resident from the wheelchair to the bed while wearing gloves only and not a gown. RNA 1 stated a gown and gloves should have been worn before transferring the resident for infection control. The IPN and DON stated staff should wear proper PPE, including gowns and gloves, during high-contact care for residents on EBP, and the facility policy required gowns and gloves for activities such as transferring and device care.
Failure to Care Plan Podiatry Refusal
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one sampled resident to address refusal of podiatry care. The resident was admitted and readmitted with diagnoses including muscle weakness and lack of coordination. The order summary showed an active order for podiatry care every two months and as needed for hypertrophic or mycotic nails. The MDS indicated the resident had severely impaired cognition for daily decision making and needed partial/moderate assistance with putting on or taking off footwear. The podiatry evaluation and treatment record dated 4/16/2026 indicated the resident refused treatment. During observation on 6/2/2026, the resident was awake in bed and had long toenails on all five toes of the right foot and the first, second, and third toes of the left foot. CNA 2 and RN 1 both stated the resident had long toenails, and RN 1 stated toenails should not be kept long to avoid anything getting caught on them and to prevent dirt from getting under the nails. Review of the resident's care plans showed no care plan developed to address podiatry care or refusal. Staff interviews confirmed there was no care plan for podiatry refusal, and the DON stated the resident had a risk for infection with long toenails and a care plan should have been developed.
Failure to Adequately Supervise High Fall-Risk Resident During Ambulation
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a newly admitted resident who was identified as high risk for falls and injuries. The resident was admitted with dementia, major depressive disorder, and schizophrenia, and was care planned on admission as being at high risk for injury, accidents, and falls, with interventions including maintaining a safe, hazard-free environment, keeping the bed in low position with bilateral floor mats, and monitoring the resident’s location as often as possible. The resident’s MDS showed moderately impaired cognitive skills for daily decision-making and a need for partial/moderate assistance with ADLs, as well as supervision or touching assistance for transfers and walking. A Fall Risk Evaluation documented intermittent confusion, balance and gait problems, decreased muscular coordination, use of assistive devices, and three or more predisposing diseases, with a total score of 20, indicating high fall risk. Despite these identified risks and care plan interventions, the resident was observed by a family member walking alone in the hallway without staff supervision, and no staff were present in the immediate area monitoring the resident. The family member reported having to search for staff and, upon informing a CNA that the resident was walking alone, the CNA did not immediately intervene. CNA2 later stated that on the date in question, she was covering another CNA’s break in the dining area and was unable to visually observe all residents, and did not see the resident ambulating in the hallway. RN1 explained that resident monitoring was done through frequent checks and staff awareness rather than continuous observation, and noted that the resident was new and staff might not have been fully familiar with the resident’s needs. The DON stated that staff were expected to follow care plans and provide monitoring, and confirmed that the resident was alert but confused, ambulatory, and required assistance with walking. The facility’s fall prevention policy required close monitoring and observation of at-risk residents for ambulation and transfer attempts with supervision and assistance as needed, which was not implemented for this resident at the time of the incident.
Failure to Complete Transfer/Discharge Notice and Notify Ombudsman for Hospital Transfer
Penalty
Summary
The facility failed to complete a Notice of Proposed Transfer/Discharge (NPTD) and failed to notify the long-term care Ombudsman when a resident was transferred to a general acute care hospital. The resident had been initially admitted with chronic pain syndrome and, per a history and physical dated several months prior, had the capacity to understand and make decisions. A subsequent MDS indicated the resident had intact cognition and was independent with daily activities and mobility. On the date of transfer, a physician order directed that the resident be transferred to another general acute care hospital via paramedics, and progress notes documented that the resident was transferred for pain. Interviews and record review showed that no NPTD was completed or filed in the resident’s medical record for this transfer. An LVN stated that the nurse who discharged the resident should have completed an NPTD during the transfer process. The DON confirmed that an NPTD could not be found in the resident’s record and stated that the NPTD should have been completed and maintained in the record. An RN explained that the NPTD’s purpose was to inform the resident of the transfer destination and the reason for the transfer, and that it was the facility’s practice to place the NPTD in the medical record as proof of completion. The facility’s policy on Proposed Transfer and Discharge Notice required that written notice be provided to the resident and, if known, a family member or representative, stating the reasons for the transfer or discharge as soon as practicable before it occurred.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from verbal, mental (emotional), and physical abuse, as evidenced by incidents involving two residents. One resident, with a history of chronic obstructive pulmonary disease, atrial fibrillation, and diabetes, was described as having intact cognition and independence in daily activities. This resident was subjected to physical abuse when another resident, who also had intact cognition and a history of intervertebral disc degeneration, osteoarthritis, COPD, and diabetes, became physically aggressive. The aggressive resident stood up from a wheelchair, grabbed the first resident by the neck, choked, and punched them in the stomach. This altercation was witnessed by staff, who observed the physical contact and subsequent injury, including a scratch on the neck that required treatment. The report also documents ongoing verbal and emotional abuse between the two residents. The aggressive resident reported being repeatedly called derogatory names, such as "crack head," by the other resident over the course of a year, despite having asked for the behavior to stop and social services having intervened multiple times. Staff interviews confirmed that the resident who was physically assaulted had a pattern of teasing and using inappropriate language toward other residents, which was recognized as verbal abuse by both nursing and administrative staff. The facility's policy defined such behavior as abuse, including the use of disparaging or derogatory language. Despite documented behavioral issues and ongoing conflict between the two residents, the facility did not prevent the escalation to physical violence or adequately protect the residents from continued verbal and emotional abuse. Staff were aware of the problematic interactions, and interventions by social services had occurred, but the abusive behaviors persisted, culminating in a physical altercation that resulted in injury. The facility's failure to prevent these incidents constituted a deficiency in protecting residents' rights to be free from all forms of abuse.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to treat two residents with dignity during mealtime assistance. For one resident with Parkinson's disease, dementia, and severely impaired cognitive skills, a CNA was observed feeding the resident while standing over the bed, with the resident's head at the CNA's waist level. The resident was in a high Fowler's position and required assistance with meals as documented in the care plan. Facility staff, including another CNA and the Director of Nursing (DON), confirmed that proper feeding technique requires staff to be seated at eye level with the resident to ensure comfort and engagement. Facility policy also specifies that feeding should be conducted in a patient, respectful, and dignified manner. A second resident, diagnosed with dementia, hemiplegia, and hemiparesis, was also observed being fed by a CNA who was standing at the bedside. This resident had severely impaired cognition and required partial to full assistance with eating and other activities of daily living. Interviews with staff and review of facility policy confirmed that staff should sit at eye level with residents during feeding to promote engagement and maintain a calm, pleasant dining environment. The observed actions were inconsistent with both facility policy and staff training, resulting in a failure to honor the residents' right to dignity during mealtime.
Failure to Follow Safe Food Handling, Storage, and Hygiene Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen to adhere to safe food handling and storage practices as outlined in the facility's own policies and professional standards. Specifically, opened boxes of frozen pineapple sherbet and strawberry ice cream in Freezer 2 were marked only with a received date and not labeled with an opened date, contrary to posted signage and policy requirements. In the walk-in refrigerator, a 36-count of white eggs was stored on top of a box of 150 eggs with no indication that the eggs were pasteurized, despite the facility's policy requiring the use of pasteurized eggs for dishes requiring raw or undercooked eggs. The Dietary Supervisor confirmed that pasteurized eggs should be used to prevent foodborne illness, especially given the vulnerability of the elderly population served. Additionally, clean dishware and kitchenware were stored face up and uncovered on shelves and utility carts, rather than being stored upside down or covered as required to prevent contamination. Staff were also observed in the kitchen and dishwashing areas without wearing required hair restraints, with one staff member handling her hair while in the dishwashing station. The Dietary Supervisor acknowledged that hair restraints are mandatory upon entering the kitchen and that the facility provides hairnets at the kitchen door. Review of facility policies confirmed the requirements for labeling opened food, using pasteurized eggs, storing kitchenware in a sanitary manner, and mandatory use of hair restraints in food service areas.
Failure to Follow Infection Control Protocols for Oxygen Equipment and Personal Toiletries
Penalty
Summary
The facility failed to implement infection control guidelines in two key areas. First, a resident with chronic obstructive pulmonary disease (COPD) and diabetes mellitus was observed using a nasal cannula (NC) for oxygen therapy that had not been changed weekly as required. The NC bag was dated nearly a month prior to the observation, and both the Licensed Vocational Nurse and the Infection Preventionist Nurse confirmed that the NC should be changed weekly to prevent bacterial accumulation, in accordance with facility policy. The resident's medical records indicated an active order for oxygen via NC as needed for respiratory symptoms and comfort. Second, the facility did not ensure that personal toiletry items were properly labeled and stored for several residents sharing a restroom. During an observation, an unlabeled, opened bottle of moisturizing shampoo and body wash was found on the window sill of a shared restroom accessible by six residents with varying degrees of cognitive impairment and assistance needs. The Certified Nursing Assistant and Infection Preventionist Nurse both stated that personal toiletries should be labeled and stored at the resident's bedside or in their drawer to prevent cross-contamination, as outlined in the facility's policies on personal hygiene items and infection control. These failures were identified through observation, interviews with staff, and review of facility policies and resident records. The deficiencies had the potential to contribute to the spread of infection within the facility, as personal care items were not managed according to established infection prevention protocols.
Call Light Not Within Reach for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility policy. During an observation, the call light was found stuck behind the resident's personal belongings, making it inaccessible. Certified Nurse Assistant 3 confirmed that the resident would not be able to find or reach the call light in its current position. The resident was assessed as high risk for falls and had severely impaired cognition, requiring significant assistance with daily activities. The resident's care plan specifically directed staff to keep the call light within reach and to answer it promptly, given the resident's history of attempting to get out of bed unassisted. The Director of Nursing also stated that the call light should be placed next to the resident's strong arm and hand to allow the resident to call for assistance. Facility policy further required that call lights be within reach when residents are in their rooms. These requirements were not met at the time of the surveyor's observation.
Failure to Complete Advance Directive Acknowledgement on Admission
Penalty
Summary
The facility failed to implement its policy and procedure regarding advance directives for one resident. Upon admission, the required Advance Directive Acknowledgement (ADA) form for this resident was not properly completed. Specifically, the ADA form did not indicate whether the resident had executed an advance directive, was missing a date for the resident's signature, and lacked the facility's signature. The facility's policy requires that ADA forms be completed within seven days of admission by the Social Services Director or designee. The resident involved had diagnoses including chronic obstructive pulmonary disease (COPD) and diabetes mellitus, and was assessed as having intact cognition and requiring some assistance with activities of daily living. During an interview, the Social Service Director confirmed that the ADA form was incomplete and stated that the resident had not executed an advance directive. The incomplete documentation meant that staff would not have clear information about the resident's care and treatment preferences in the event of an emergency.
Failure to Designate Staff for Hospice Coordination
Penalty
Summary
The facility failed to designate a member of its Interdisciplinary Team (IDT) to coordinate care with hospice representatives for a resident who was receiving hospice services. The resident, who had diagnoses including adult failure to thrive and rhabdomyolysis, required substantial to maximal assistance for personal hygiene and dressing, and had unclear speech with limited ability to communicate. The resident was readmitted to the facility under hospice care, and hospice visitation schedules indicated that a Certified Home Health Aide (CHHA) was supposed to visit on specific dates. However, a review of the hospice staff sign-in logs showed no evidence that the CHHA signed in or provided care on the scheduled dates. The Director of Nursing (DON) confirmed that there was no designated staff member responsible for coordinating with hospice staff or monitoring their scheduled visits. Additionally, the facility lacked a policy or procedure for assigning a staff member to coordinate hospice services, resulting in an inability to verify whether the resident received the necessary hospice care as scheduled.
Unsanitary Electric Fan in Resident Room
Penalty
Summary
A deficiency was identified when an electric fan in a resident's room was found to be in an unsanitary condition. During an observation and interview, a black standing fan at the resident's bedside was noted to have dust on the blades and lint on the cover. The Licensed Vocational Nurse present acknowledged that the fan was not clean and stated that the resident could potentially inhale the dust and lint. The resident in question had moderately impaired cognition and required assistance with showering and personal hygiene, as documented in their Minimum Data Set. The resident's medical history included hypertension, anxiety, and osteoarthritis. Further interviews revealed that the Director of Nursing expected housekeeping staff to keep all equipment in residents' rooms clean and in good working condition to prevent respiratory-related illnesses. A review of the facility's Homelike Environment Policy indicated that regular housekeeping and maintenance should be provided while preserving residents' personal touches. The failure to maintain the fan in a clean and sanitary condition constituted a deficiency in ensuring a safe, clean, and comfortable environment for the resident.
Failure to Implement Employee Screening Policies
Penalty
Summary
The facility failed to implement its written policies and procedures for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of property. Specifically, the facility did not obtain information from previous employers for four sampled Certified Nursing Assistants (CNAs). The Director of Staff Development (DSD) was responsible for conducting reference checks but only contacted the most recent employer and sometimes used personal knowledge as a second reference. This practice did not align with the facility's policy, which required at least two reference checks from current and previous employers. During interviews and record reviews, it was revealed that the DSD often did not document attempts to contact references, making it difficult to verify the thoroughness of the screening process. The facility's policy, titled Patient Abuse Prevention, required informing previous employers of the intention to uncover any past criminal prosecutions or allegations of abuse. The Administrator confirmed that the DSD was responsible for this screening process and acknowledged the failure to adhere to the policy, which had the potential to expose residents to abuse, neglect, exploitation, or misappropriation of property.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect Resident 1 from verbal and physical abuse by Resident 2, as per the facility's Abuse Prevention policy. Resident 1, who was readmitted to the facility with multiple diagnoses including osteoarthritis and anxiety, was involved in an altercation with Resident 2. Resident 1, who had moderate cognitive impairment and required assistance with daily activities, was scratched on the right hand by Resident 2, resulting in an open cut. The incident occurred after a verbal disagreement over the room light, and later, Resident 2 approached Resident 1, yelled, and hit them on the hand. Resident 2, who was diagnosed with schizophrenia and depression, had a history of aggressive behavior and was under orders for one-to-one monitoring due to these tendencies. However, on the day of the incident, the assigned CNA left Resident 2 unattended to use the restroom without informing another staff member, leaving Resident 2 unsupervised. This lapse in supervision allowed Resident 2 to engage in the altercation with Resident 1, which was not immediately addressed by staff. The facility's policies on Abuse Prevention and One-on-One Monitoring were not adhered to, as continuous supervision was not maintained for Resident 2. The Director of Nursing acknowledged that the CNA should have informed another staff member before leaving Resident 2 unattended. The lack of adherence to the monitoring policy and the absence of staff during the incident contributed to the failure to prevent the abuse of Resident 1 by Resident 2.
Failure to Report Alleged Abuse Within Required Timeframe
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe as per their policy and procedure titled 'Abuse Prevention.' On March 6, 2025, a resident reported to the Social Services Assistant (SSA) that another resident had hit them. Despite the report, the SSA did not inform anyone about the allegation, which was a violation of the facility's policy and legal requirements. The SSA acknowledged the importance of reporting such incidents to prevent further abuse and to determine the facts of the situation. The deficiency involved two residents: one who reported being hit and another who was accused of hitting. The resident who reported the incident was cognitively intact and capable of making decisions, while the accused resident had a diagnosis of schizophrenia and was moderately cognitively impaired. Interviews with various staff members, including the Director of Staff Development and the Administrator, confirmed that all staff were mandated reporters and that any allegations of abuse should be reported within two hours to the appropriate authorities, including the Department of Health and the LTC Ombudsman.
Failure to Submit PBJ Staffing Data Report
Penalty
Summary
The facility failed to ensure that the Payroll Based Journal (PBJ) staffing data report was submitted quarterly as required by the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2023. During a review of the facility's Certification and Survey Provider Enhanced Reports (CASPER) 1705D, it was found that the PBJ Staffing Data Report indicated a failure to submit data, resulting in a one-star staffing rating. Interviews with the Payroll Human Resources (PHR) and the Business Office Manager (BOM) revealed that there were no records of proof indicating the previous BOM submitted the PBJ data for the specified period. Handwritten notes were found, but no official records of data submission to CMS were available. The Administrator (ADM) confirmed that the facility had no records of proof of submission of PBJ data and no records that CMS received them for the first quarter of 2023. The ADM acknowledged that handwritten notes on PBJ were not official and emphasized the importance of submitting accurate PBJ reports to CMS before the deadline to maintain compliance with federal regulations. A review of the facility's Policy and Procedure (P&P) on PBJ Reporting Policy indicated that the human resources department is responsible for overseeing PBJ reporting and ensuring compliance with federal regulations. The failure to submit the PBJ report on time could affect the facility's star rating and indicate a staffing concern for the facility.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, leading to potential delays in care and increased risk of falls. Resident 31's bathroom did not have a call light cord, which was confirmed through observations and interviews with the resident, an LVN, and the DON. The resident's care plan indicated a high risk for falls and required the call light to be within reach, but this was not adhered to. The facility's policy also mandated that call lights be within reach, but this was not followed in Resident 31's case. Similarly, Resident 7's call light was not within reach as it was stuck behind the roommate's walker. This was observed and confirmed by an LVN and the DON. Resident 7's care plan also indicated a high risk for falls and required the call light to be within reach. The facility's policy on call lights was not followed, putting Resident 7 at risk. Both residents had significant medical histories that made the availability of call lights crucial for their safety and timely care.
Failure to Supervise Residents Adequately
Penalty
Summary
The facility failed to supervise two residents adequately, leading to potential safety hazards. Resident 67, who had a history of wandering due to dementia and schizophrenia, was observed wandering into other residents' rooms in search of cigarettes. Despite having a Wanderguard and a care plan indicating frequent monitoring, the facility did not implement specific interventions to address this behavior. Multiple residents reported feeling uneasy and witnessing Resident 67's wandering behavior, which was not adequately addressed by the staff or reflected in the care plan. Resident 70, assessed as high risk for falls, was not provided continuous one-to-one monitoring as required by their care plan. Observations revealed that Resident 70 was left unattended multiple times, despite the assigned CNAs acknowledging the need for continuous supervision. The facility's monitoring logs confirmed that the assigned staff failed to maintain continuous visual supervision, leaving Resident 70 at risk of falling again. Interviews with staff, including the Director of Nursing and Social Services Director, confirmed the lapses in supervision and the inadequacy of the existing care plans. The facility's policies on supervision and one-on-one monitoring were not followed, leading to potential safety risks for both residents. The staff acknowledged the need for more effective interventions and continuous monitoring to ensure resident safety.
Medication Administration and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered and disposed of according to its policy and procedure. Specifically, a Licensed Vocational Nurse (LVN) split a Depakote Extended Release (ER) 500 mg tablet in half and administered it to a resident with a seizure disorder, contrary to the physician's order and the medication's intended use. The resident's care plan indicated that medications should be administered as ordered, and the facility's policy stated that extended-release medications should not be altered. The LVN acknowledged that there was no physician order to break the Depakote ER in half and that doing so could affect the medication's efficacy. The Director of Nursing (DON) and the facility's Pharmacy Consultant confirmed that Depakote ER should not be split, as it would modify the medication's release and effectiveness. Additionally, the facility did not follow its policy for the destruction of discontinued medications. The policy required that two licensed nurses witness the destruction of medications, but an Activity Assistant (AA) was tasked with this responsibility, supervised by only one licensed nurse. The DON admitted to instructing the AA to help with medication disposal, which was against the facility's policy. The AA confirmed that only one licensed nurse was present during the medication destruction process, contrary to the policy that required two licensed witnesses.
Failure to Monitor and Provide Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to monitor and provide a Gradual Dose Reduction (GDR) for two residents, leading to the potential use of unnecessary psychotropic medications. For Resident 67, a GDR was not completed for the use of Trazodone 100 mg, and no clinical rationale was documented. Despite consistent sleep patterns, the Nurse Practitioner (NP) did not attempt a GDR, and the Director of Nursing (DON) acknowledged that the GDR request was missed. The Psychiatric Progress Note and the Note to the Attending Physician/Prescriber did not provide specific benefits for the continued use of the medication, and the Pharmacist Consultant emphasized the importance of documenting failed GDR attempts and following up accordingly. For Resident 7, the facility did not monitor behaviors related to the use of Zyprexa for schizophrenia during specific night shifts. The care plan required staff to evaluate the effectiveness of Zyprexa and monitor paranoid delusions, but there was no documented monitoring for the specified dates. Both the Registered Nurse (RN) and the DON confirmed the lack of monitoring, which was necessary to determine the medication's effectiveness. The facility's policy indicated that all residents receiving psychotropic medications should be monitored for effectiveness and adverse reactions, but this was not followed in Resident 7's case. These deficiencies highlight the facility's failure to adhere to its own policies and procedures regarding the use of psychotropic medications. The lack of proper documentation and monitoring for GDR and behavior assessments could lead to the continued use of unnecessary medications, posing potential risks to the residents involved.
Expired Milk Not Discarded
Penalty
Summary
The facility failed to follow required food sanitation and handling practices by not discarding six glasses of expired milk found in the kitchen refrigerator. During an initial kitchen tour with the Dietary Supervisor (DS), it was observed that the milk was outdated and should not have been left inside the refrigerator past the expiration date. The DS acknowledged that consuming expired milk could cause food-borne illnesses such as diarrhea and vomiting and stated that expired food should be removed and discarded by the end of the expiry date. A review of the facility's Policy and Procedure (P&P) on Food Receiving and Storage of Cold Foods indicated that poured beverages like milk should be labeled, dated, and discarded at the end of the day.
Infection Control Policy Violations
Penalty
Summary
The facility failed to follow infection control policy and procedures by not ensuring that a Certified Nursing Assistant (CNA) wore the required personal protective equipment (PPE) before entering a contact isolation room for a resident diagnosed with MRSA. The CNA entered the resident's room, picked up the resident's call light from the floor, and placed it back on the bed linen without wearing gloves or other PPE. The resident's care plan indicated the need for isolation precautions, and the facility's policy required staff to wear appropriate PPE when entering the room of a resident with a contagious infection. The Infection Preventionist Nurse confirmed that staff needed to wear PPE to prevent the transmission of infection and protect other residents. Additionally, the facility failed to ensure that food was not stored in the medication storage room. During an observation, a box of doughnuts was found on top of the medication cabinet. The Registered Nurse and Director of Nursing both stated that food should not be stored in the medication room and should be kept in the employee break room. The facility's policy on food storage indicated that food should be stored properly to maintain safety and prevent contamination. The Infection Prevention Nurse also confirmed that food should be stored in the employee lounge to prevent the spread of infection.
Failure to Ensure Privacy During G-Tube Check
Penalty
Summary
The facility failed to ensure privacy for Resident 42 while checking the gastrostomy tube (G-tube) site. During an observation, Licensed Vocational Nurse 1 (LVN 1) opened the resident's gown and checked the G-tube site without closing the privacy curtain, thereby exposing the resident's abdominal area. This action was contrary to the facility's policy on providing privacy during activities of daily living (ADL) and the resident's care plan, which required nursing staff to provide privacy at all times. LVN 1 acknowledged that the privacy curtain should have been closed to maintain the resident's dignity and privacy. Resident 42, who was admitted to the facility on 8/28/2017 and readmitted with diagnoses including chronic obstructive pulmonary disease (COPD), epilepsy, and a need for attention to the gastrostomy, did not have the capacity to understand and make decisions. The resident's care plan indicated muscular weakness and dementia, requiring maximum assistance with various ADLs. The Director of Nursing (DON) confirmed that the privacy curtain should have been closed to maintain the resident's privacy and dignity. The facility's policy emphasized treating residents with dignity, respect, and sensitivity, and required the use of closed doors, curtains, or partitions to provide privacy during ADLs.
Failure to Develop Care Plan for Wandering Resident
Penalty
Summary
The facility failed to develop a care plan for Resident 67, who exhibited wandering behavior by entering other residents' rooms. Resident 67, diagnosed with dementia, schizophrenia, and anxiety, was observed wandering alone in the hallways and entering other residents' rooms. Multiple residents reported that Resident 67 frequently entered their rooms, sometimes attempting to take items such as cigarettes. Despite these reports and observations, there was no care plan addressing Resident 67's wandering behavior, which was confirmed by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). The facility's policy required care plans to be updated based on specific behaviors, but this was not done for Resident 67's wandering behavior. Interviews with staff, including the Social Services Director (SSD) and the DON, revealed that the facility's usual response to wandering behavior was to redirect the resident to activities and notify the family. However, this approach was not documented in a care plan for Resident 67. The SSD and DON acknowledged that the care plan should have been updated to include specific interventions for Resident 67's wandering behavior. The facility's policy on care plan revision emphasized the need for measurable objectives and timetables to meet the resident's needs, which was not adhered to in this case.
Failure to Conduct Timely IDT Care Planning Conference
Penalty
Summary
The facility failed to conduct an Interdisciplinary Team (IDT) care planning conference for Resident 184 in accordance with its Policy and Procedure (P&P) titled Care Planning Interdisciplinary Team. Resident 184 was admitted to the facility with diagnoses including type 2 diabetes mellitus and anemia. The Minimum Data Set (MDS) indicated that Resident 184 had clear speech and the ability to understand others and make self-understood. However, during an interview and record review, the Director of Nursing (DON) confirmed that Resident 184 did not have an IDT care planning conference within the required timeframe. An empty form titled Admission / 72 hours IDT Conference was found in Resident 184's medical record, indicating that the conference was not conducted as required. The DON stated that the IDT conference should have been completed within 72 hours after admission, but it was missed and delayed for Resident 184. The facility's P&P indicated that a comprehensive care plan should be developed within seven days of the resident assessment, involving multiple departments and the resident or responsible party to create a person-centered plan of care. The failure to conduct the IDT care planning conference in a timely manner had the potential to prevent Resident 184 from receiving appropriate care and treatment promptly.
Failure to Monitor Resident During Mealtime
Penalty
Summary
The facility failed to ensure that Resident 5 was assessed and monitored during mealtime as indicated in the resident's care plan. Resident 5, who has diagnoses including Parkinson's disease and osteoarthritis, was observed eating alone in her room with her right hand shaking, causing food to spill on the tray. This lack of supervision during mealtime was contrary to the care plan interventions, which specified that the resident should be monitored during meals due to the potential for injury from tremors and involuntary movements. Additionally, the care plan indicated the need to observe the resident for a decline in mobility and function and to notify the medical doctor promptly, which was not done in this case. Interviews with the Dietary Supervisor and the Registered Nurse Supervisor revealed that Resident 5's increased hand tremors had been noticed, but there were no records indicating that the resident was assessed and monitored during mealtime or that the medical doctor or occupational therapist were notified of the increased tremors. The Director of Nursing confirmed that mobility assessments are typically done annually, quarterly, and as needed, but there was no documentation to support that these assessments were conducted for Resident 5. The facility's policy on Assistance with Meals, which requires residents to receive meal assistance in a manner that meets their individual needs, was not followed in this instance.
Failure to Implement Repositioning Interventions
Penalty
Summary
The facility failed to implement the intervention on the resident's care plan for turning and repositioning every 2 hours for Resident 23, who was at risk for skin breakdown due to impaired mobility and incontinence. Despite the care plan and the Resident Positioning Log indicating that Resident 23 should be turned and repositioned every 2 hours, multiple observations on 4/24/2024 showed that Resident 23 remained in the same position for extended periods, specifically on her left side facing the door from 9:07 am to 2:08 pm, before being repositioned on her back at 2:52 pm. Interviews with CNA 3 and the DON confirmed the importance of turning and repositioning every 2 hours to prevent skin breakdown for residents with poor mobility. The DON acknowledged that Resident 23 needed to be turned and repositioned at least every 2 hours. However, the observations and the review of the Resident Positioning Log indicated that this intervention was not consistently implemented, placing Resident 23 at risk for developing skin breakdown.
Failure to Maintain Clean Oxygen Tubing
Penalty
Summary
The facility failed to ensure that a resident's nasal cannula tubing was not touching the trash bin, which is against professional standards of practice and the facility's own Infection Control Policy: Oxygen Use. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD) and heart failure, was observed with their oxygen tubing in contact with the trash bin while eating breakfast. This observation was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged that the tubing should not be touching the trash bin due to the risk of infection and contamination. The Director of Nurses (DON) also confirmed that oxygen tubing should not be in contact with the trash bin to prevent infection and cross-contamination. The facility's policy, dated April 2018, states that oxygen equipment should be inspected regularly for signs of damage, wear, or contamination, and that any damaged or contaminated equipment should be replaced or repaired promptly. The failure to adhere to this policy had the potential to increase the risk of infection for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near El Monte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Gardens Of El Monte | 0.6 mi | ★★★★★ | 26 | 0 |
| Temple City Healthcare | 0.7 mi | ★★★★★ | 34 | 0 |
| Santa Fe Lodge | 1.1 mi | ★★★★★ | 23 | 0 |
| Mayflower Care Center | 1.1 mi | ★★★★★ | 3 | 0 |
| Madera Post Acute Center | 1.2 mi | ★★★★★ | 25 | 0 |
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