Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fireside Health Care Center during CMS and state inspections, most recent first.
Delayed Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments within required timeframes for five sampled residents. The MDSC stated the delays were due to workload, and several assessments were either overdue, started but not completed, or not submitted on time. The DON stated the MDS should be submitted within CMS timeframes and is important because it identifies the information needed to care for the resident.
Improper Food Labeling and Ice Scoop Cleaning Documentation: An open mayonnaise and ranch dressing in the refrigerator did not have use-by dates, and the ice scoop cleaning log had missing initials on weekend entries with no documented cleaning date on the scoop. The DS and DON stated open refrigerated items require open and use-by dates, and ice scoops are to be cleaned daily with date and staff initials documented.
A facility failed to ensure that 28 of 32 rooms met the required square footage per resident, including twenty-five 2-bed rooms, two 3-bed rooms, and one 4-bed room. Surveyors reviewed the Client Accommodation Analysis and found the rooms below minimum size standards, while resident interviews noted cramped conditions in one room with BiPAP, O2, and a wheelchair, and another room where a Hoyer lift would not fit for transfers.
A resident with difficulty walking, HTN, and lack of coordination was not given the SNFABN after Medicare Part A skilled coverage ended. The SNF Beneficiary Protection Notification Review Form showed the notice was not provided, and the SSD, MDSC, and DON all confirmed the resident should have received it; the MDSC noted the omission may leave the resident unaware of the right to appeal.
A resident with cognitive impairment, atrial fibrillation, DM, and dementia was observed receiving ADL care while the privacy curtain was only partially closed. A CNA stated the curtain was not fully closed during care and was closed only when the surveyor entered the room. The DON stated staff must fully close privacy curtains during personal care to protect resident dignity and privacy.
Missing Care Plan for Anticoagulant Therapy: A resident with A-fib, DM, and coronary artery bypass graft history was ordered apixaban 5 mg BID, but the chart did not contain a care plan for the anticoagulant. The RNS confirmed the omission and stated the medication is a blood thinner that requires monitoring for bleeding, while the DON stated a care plan should guide resident care and monitoring.
Failure to obtain physician orders for a resident's right and left buttock pressure injuries resulted in no documented wound treatment at admission. The resident was admitted with pressure-induced tissue damage, had intact cognition, and required substantial assistance with ADLs. An LVN stated the wound orders were not obtained until later and there was no documentation of the wounds until after admission, while the DON stated the orders should have been obtained upon admission and that the wounds were not addressed.
Incorrect Oxygen Flow Rate: A resident with respiratory failure with hypoxia was ordered continuous oxygen at 2 LPM via NC, but during observation the oxygen concentrator was set at 1 LPM and the NC was on the resident’s face but not in the nose. An LVN confirmed the order required 2 LPM, and the DON stated nurses must follow the physician order when administering oxygen.
Failure to Reassess and Administer Ordered Pain Medication: A resident with osteoarthritis and other chronic conditions reported severe pain that was treated with scheduled Tylenol, but staff did not document pain reassessment after administration and did not offer or give ordered PRN oxycodone for several days despite the resident reporting 8/10 pain. The EMAR and nurses’ notes lacked follow-up pain evaluations, and both LPNs interviewed stated they did not reassess pain after giving Tylenol. The DON stated nurses are expected to follow pain medication orders and reassess after administration.
A resident with ESRD and dialysis dependence did not receive ordered Epogen on multiple dialysis days. Records showed the medication was unavailable, with no documentation that it was given at the dialysis center or that staff contacted the pharmacy or clarified responsibility with the physician and dialysis center. The DON stated the order was believed to be for facility administration, while the pharmacy believed the dialysis center would give it, and the dialysis center reported the resident was receiving Mircera instead.
Failure to Isolate Resident with ESBL: A resident with a urine culture positive for ESBL and an order for contact isolation was observed sharing a room with other residents and later on the patio with them. Staff, including an LVN, IP nurse, and DON, stated the resident should have been in a single room because ESBL required contact isolation and could be transmitted if precautions were not followed.
A resident who was dependent for personal care and had multiple medical conditions was subjected to aggressive perineal care by a family member, despite expressing pain and asking for it to stop. The CNA reported the suspected abuse to the RN, who was unfamiliar with the reporting process and delayed notifying the appropriate authorities, including APS, the Ombudsman, and law enforcement, as required by facility policy.
Surveyors found that the facility did not display the current Administrator's license, instead posting the license of a former Administrator. The current Administrator reported not having a copy of his license due to it being mailed to the wrong address and lacking the means to print another copy. The facility also lacked a policy for the Administrator's license.
Two residents reported missing personal property, including a damaged cell phone and various clothing items, and stated that repeated requests to speak with the social worker were ignored. Staff failed to complete required inventory lists upon admission and did not investigate the reports of missing property, contrary to facility policy.
A resident with a history of alcohol abuse and medical conditions eloped from the facility due to inadequate supervision and non-functional alarm systems on exit doors. The resident was cognitively intact but required assistance with daily activities. The facility failed to conduct an elopement assessment upon admission and did not include specific interventions in the care plan. The alarm system on several exit doors was either non-functional or not activated, leading to a delayed response from staff. The resident was found the following day, highlighting lapses in supervision and safety protocols.
A facility failed to properly waste an Ativan 0.5 mg tablet according to its controlled narcotic protocol, resulting in an inaccurate medication count for a resident with multiple diagnoses. The LVN admitted to giving one tablet and failing to document it, as well as dropping another tablet during the count, which was not wasted as per protocol. The waste was not properly documented or witnessed by two licensed nurses, as required by the facility's policy.
A resident with a history of cervical disc disorder and other conditions experienced unmanaged pain due to the facility's failure to administer prescribed oxycodone-APAP for 18 out of 54 days. The medication was not available because the pharmacy did not receive authorization from the physician, and the facility did not follow up to resolve the issue. This resulted in the resident experiencing significant pain and frustration, as well as an inability to participate in activities.
A facility failed to obtain and maintain a PASRR level I screening for a resident with mental health diagnoses, including bipolar disorder and dementia. The absence of this screening was identified during a review of the resident's admission records and interviews with staff, revealing a lack of adherence to the facility's policy. The Social Services Director and Admissions Director were unaware of the PASRR process, and the Director of Nursing acknowledged the missing documentation, which is crucial for addressing the resident's mental health needs.
A resident with a displaced fracture of the second cervical vertebra was observed without a neck brace, contrary to the physician's order to wear it at all times. The neck brace was found next to the resident, and both a PT and RN confirmed the requirement for the brace to prevent further injury and pain. The facility's policy supported the need for adherence to the physician's order.
A resident with chronic respiratory failure reported that her Bipap machine was not cleaned daily as required by physician orders. Facility staff, including the DSD and LVNs, lacked proper training and documentation on the cleaning and operation of the Bipap machine, leading to potential respiratory infection risk for the resident.
The facility failed to ensure staff competency in operating and cleaning Bipap machines and maintaining current CPR certification. A resident with chronic respiratory failure reported that their Bipap machine was not cleaned daily. The DSD admitted to a lack of structured training and materials for staff. Additionally, five staff members lacked current CPR certification, and some were unable to demonstrate basic CPR skills. The facility's policies required proper training and certification, but these were not adhered to, posing potential harm to residents.
A resident with multiple health conditions experienced significant discomfort due to a malfunctioning bed and a worn-out mattress. Despite reporting the issue to the Maintenance Supervisor, no corrective action was taken. Observations confirmed the bed's malfunction and the poor condition of the mattress, posing risks of injury and infection. The facility's policy for regular bed inspections was not followed.
A facility failed to complete a required PASRR Level II assessment for a resident with major depressive disorder and PTSD, as indicated by a positive Level I screening. The resident was admitted and readmitted with these diagnoses, and the oversight was confirmed during an interview with the DSD. The facility's policy requires a Level II review within 40 days of admission, which was not followed.
Two residents' room entrance was obstructed by wheelchairs filled with boxes, creating a safety hazard. One resident was cognitively intact but needed assistance with daily activities, while the other had severe cognitive impairment and was fully dependent on staff. The obstruction could delay emergency access, violating the facility's policy for a safe environment.
A resident with an indwelling catheter showed signs of a UTI, such as cloudy urine with sediments, but the facility staff failed to monitor and report these signs to a physician. Despite the resident's care plan requiring such monitoring, no change of condition was noted, leading to a delay in treatment. The facility's catheter care policy, which emphasizes checking urine for unusual appearance, was not followed.
A facility failed to label a resident's feeding tube syringe with the date it was opened, as observed during a survey. The resident, who had multiple medical conditions and was dependent on staff, was at risk of infection due to this oversight. The facility's policy required labeling to prevent contamination, which was not followed.
The facility failed to maintain infection control measures, with deficiencies observed in resident rooms lacking proper sanitation facilities, improper handling of urinals and commodes, and inadequate cleaning of a resident's Bipap machine. Staff and visitors used restrooms intended for residents, and a garbage can for waste was improperly stored in a shower room. Staff lacked training on Bipap machine maintenance, posing infection risks.
A facility failed to ensure a Restorative Nurse Assistant (RNA) was properly certified and trained before providing care. The RNA's CNA, CPR, and RNA training certificates were missing from their file, violating facility policy. The Director of Staff Development acknowledged the oversight and expressed concern about potential harm to residents due to inadequate training in therapeutic rehabilitation techniques.
The facility failed to meet the required 80 square feet per resident in 28 out of 32 rooms, including 2-bed, 3-bed, and 4-bed rooms. Despite observations that nursing staff had adequate space to provide care and residents did not express concerns, the rooms did not meet the minimum square footage requirements. A room waiver request was submitted, acknowledging the deficiency.
A resident with severe cognitive impairments was discharged from an LTC facility without receiving the necessary hospice information as ordered by the physician. The family member reported that no hospice options were provided while the resident was in the facility, leading to confusion and a tedious discharge process. The facility's social worker and administrator acknowledged the lapse, with the hospice information being provided only after the resident's discharge.
The facility failed to manage medications for discharged or transferred residents, leaving multiple medications in the storage room accessible to staff. Medications were not returned or destroyed per policy, as observed in four residents' cases. Staff interviews revealed a lack of adherence to medication destruction procedures, with some staff unaware of the facility's policies.
A facility failed to secure controlled substances of a discharged resident and did not store discontinued controlled substances per policy. A resident's medications, including Hydromorphone and Morphine, were found unsecured in the medication storage room. Additionally, the DON had a cabinet with controlled substances that were not double-locked as required. The facility's policy mandates monthly monitoring by a pharmacist, but the last waste of narcotics was in August, with a missed waste in September due to an unavailable interim DON.
The facility failed to ensure the Medical Director's application was filed with the State Licensing and Certification department, resulting in the MD not being listed in the Electronic Licensing Management System. Interviews confirmed the presence of a Medical Director, but the application was still being prepared for submission. The MD was not part of the governing body but participated in Quality Assessment and Assurance meetings.
A resident with cognitive impairment and significant care needs was transferred to another SNF without receiving the required advance notice. The Social Services Director acknowledged informing the resident of the discharge only an hour before it occurred, without notifying the Ombudsman, contrary to the facility's policy requiring a 30-day notice unless urgent circumstances exist.
A facility failed to develop an individualized discharge care plan for a resident with hemiplegia, PTSD, and major depressive disorder, leading to confusion and anxiety. Despite the resident's moderate cognitive impairment and need for substantial assistance, no discharge plan was initiated, as confirmed by the SSD and DON. The facility's policy requires such plans, but it was not followed.
A resident with severe cognitive impairment was physically abused by a caregiver due to the facility's failure to implement its abuse prevention policies. The caregiver, hired privately by another resident's family, had not undergone required orientation or background checks. The resident was left alone with the caregiver despite a verbal altercation, leading to the abuse. The facility lacked proper supervision and documentation, contributing to the incident.
A resident with cognitive impairment was allegedly slapped by a caregiver during a heated conversation. The incident was reported to the administrator and police, but the facility failed to notify the State Survey Agency within the required two-hour timeframe, as per their abuse prevention policy.
A resident was issued a 30-day discharge notice due to alleged aggression, but the facility failed to provide necessary physician documentation to support the discharge. The resident's appeal was granted as the facility did not have the attending physician assess the resident or document that the resident's presence endangered safety, as required by policy.
A resident with mild cognitive impairment alleged that a CNA attempted to hit him during a disagreement over breakfast service. The CNA denied the allegations, and the LVN, who was informed of the incident, did not report it to the ADON or Administrator as required by facility policy. The incident was not reported until a surveyor's interview, highlighting a failure in mandatory reporting procedures.
A facility failed to develop and implement a proper discharge plan for a resident with terminal cancer, resulting in the resident not receiving necessary hospice care. The Social Services Director referred the resident to a hospice agency without a contract or detailed service documentation, and the family was not provided with written information about the agency.
Delayed Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly MDS assessments timely for five of five sampled residents reviewed under the Resident Assessment task. During a concurrent interview and record review with the MDS Coordinator, it was confirmed that quarterly MDS assessments must be completed every three months, and the MDS Coordinator stated the assessments were overdue due to workload. The review identified that Resident 23’s last quarterly MDS was submitted on 1/19/2025, with the quarterly assessment started on 12/12/2025 and due by 12/26/2025. Resident 33 and Resident 39 each had quarterly MDS assessments submitted on 1/19/2025 and were due by 12/30/2025. Resident 41’s quarterly assessment was started on 12/22/2025 but was not completed, and it should have been completed and submitted by 1/5/2026. Resident 43’s quarterly assessment was started on 12/19/2025 and had not been completed. During interview, the DON stated that the MDS tells the complete story of the resident and should be submitted within CMS timeframes, and that the quarterly MDS is important because it identifies the information needed to care for the resident. The facility policy titled Resident Assessments stated that quarterly assessments are to be conducted not less frequently than every three months following the most recent OBRA assessment of any type.
Improper Food Labeling and Ice Scoop Cleaning Documentation
Penalty
Summary
Food was not stored under sanitary conditions and food preparation equipment was not maintained as required when an open whole egg mayonnaise and a butter milk ranch dressing in the refrigerator did not have a use-by date noted on the containers. During a concurrent observation and interview on 1/20/2026 at 8:10 A.M., the Dietary Supervisor stated the items had been opened on 12/1/2025, but there was no use-by date documented. The Dietary Supervisor stated open refrigerated items need a delivery date, open date, and use-by date, and that the use-by date is used to track storage time and prevent use beyond the allowed date. The facility also failed to document daily cleaning of the ice scoop. During a concurrent observation and interview on 1/20/2026 at 8:23 A.M., the Dietary Supervisor stated ice scoops are cleaned daily and staff are to place a date on the scoop when cleaned and initial the dietary department cleaning and sanitization schedule. The cleaning log for 1/1/2026 through 1/20/2026 had Saturdays and Sundays blocked out in black with no initials noted. During an interview on 1/23/2026 at 12:17 P.M., the DON stated ice scoops need to be cleaned daily and documented with the date and initials of the staff performing the task, and that if there is no documentation of ice scoop cleaning, then it was not done.
Insufficient Room Space in Multiple-Resident Rooms
Penalty
Summary
The facility failed to ensure that 28 of 32 rooms met the required 80 square feet per resident in multiple-resident rooms. These 28 rooms included twenty-five 2-bed rooms, two 3-bed rooms, and one 4-bed room. The report states that the minimum requirement for a 2-bed room was 160 square feet, for a 3-bed room 240 square feet, and for a 4-bed room 320 square feet, but the Client Accommodation Analysis dated 1/20/2026 showed that the listed rooms did not meet those standards. During the initial tour, evaluators inspected the rooms and observed that nursing staff had enough space to provide care, there were curtains for privacy, and the rooms had direct access to the corridors. In a group interview, one resident stated that the room felt a bit cramped because it contained a BiPAP, oxygen concentrator, and wheelchair, though the resident believed the room size was adequate because of the equipment. Another resident stated that when he stayed in a room, the Hoyer lift needed for transfers would not fit, and he was moved to a different room. The residents did not report complaints about the room sizes.
Failure to Provide SNF ABN Notice
Penalty
Summary
The facility failed to provide Resident 77 with the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) after the resident’s last covered Medicare Part A skilled day ended. Resident 77 was re-admitted with diagnoses including difficulty walking, high blood pressure, and lack of coordination. The resident’s SNF Beneficiary Protection Notification Review Form showed the last covered Medicare Part A skilled service day was 8/12/2025 and that the SNFABN was not provided. The resident was later discharged from the facility on 9/26/2025. During interviews, the SSD stated Resident 77 was not given the SNF ABN and confirmed the last covered day was 8/12/2025. The MDSC also stated the resident was not given the SNF ABN form and should have received it, noting that not receiving the notice may result in the resident not knowing about the right to appeal. The DON stated beneficiary notices should be given when required and that they tell residents of their right to appeal.
Failure to Maintain Resident Privacy During ADL Care
Penalty
Summary
The facility failed to maintain and protect Resident 3’s privacy, including bodily privacy, during assistance with ADL care. Resident 3 was admitted on 7/22/2025 and readmitted on 8/18/2025 with diagnoses including atrial fibrillation, DM, and dementia. The MDS dated 10/29/2025 indicated the resident was cognitively impaired and required partial/moderate to dependency on staff for ADLs. During an initial tour on 1/20/2026 at 9:23 A.M., Resident 3 was observed in bed while CNA 3 was providing ADL care with the privacy curtain only partially closed. When the surveyor entered the room, CNA 3 fully closed the curtain. In interview, CNA 3 stated she did not fully close the privacy curtains while providing care and only closed them when the surveyor was present, and stated the curtains need to be fully closed for privacy and dignity. The DON later stated staff need to pull the privacy curtains all the way when providing ADL care so no other people can see the resident during care, and that leaving the curtain partially open may make residents feel their privacy has been invaded or violated. The facility’s P&P stated that residents are treated with dignity and respect at all times and that staff promote, maintain, and protect resident privacy during personal care and treatment procedures.
Missing Care Plan for Anticoagulant Therapy
Penalty
Summary
Facility failed to develop a comprehensive care plan for Resident 7’s apixaban therapy in accordance with its Care Plans, Comprehensive Person-Centered policy. Resident 7 was admitted on 6/2/2025 and readmitted on 10/28/2025 with diagnoses including paroxysmal A-fib, DM, and atherosclerosis of coronary artery bypass graft. The MDS dated 12/10/2025 indicated the resident was cognitively intact and required supervisory/touch to setup/clean up assistance with ADLs. The order summary report showed apixaban 5 mg by mouth twice daily for A-fib, with an order date of 10/7/2025 and start date of 10/8/2025. During concurrent interview and record review on 1/22/2026, the RNS reviewed the chart and stated Resident 7 did not have a care plan for the anticoagulant. The RNS stated apixaban is an anticoagulant that places residents at high risk for bleeding and that signs and symptoms of bleeding need to be reported to the doctor. The DON later stated that a care plan should be initiated upon admission, as needed, quarterly, and annually, and that a blood thinner care plan is a guide for how the facility should care for the resident, including monitoring and care approach.
Failure to Obtain Wound Treatment Orders for Buttock Pressure Injuries
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to obtain physician's orders to treat Resident 73's right and left buttock pressure ulcers from 1/9/2026 to 1/13/2026. Resident 73 was admitted on 1/9/2026 with diagnoses including a left femur fracture, pressure-induced tissue damage of the left and right buttock, and major depressive disorder. The admission/readmission screener dated 1/9/2026 indicated pressure ulcers were present with open areas on both buttocks, and the MDS dated 1/16/2026 indicated the resident's cognition was intact, the resident required substantial assistance with showering, dressing, and personal hygiene, and the resident had two unstageable pressure injuries. The physician's orders dated 1/13/2026 directed treatment for the right buttock deep tissue injury and the left buttock deep tissue injury, including cleansing with normal saline and application of Medihoney or zinc barrier cream with dry clean dressings. During interview and record review, LVN 5 stated the nursing staff did not obtain treatment orders for the wounds at admission, that physician orders were not obtained until LVN 5 returned to work, and that there was no documentation of the wounds until 1/14/2026. The DON stated the treatment orders should have been obtained upon admission and that not receiving orders meant the resident's wounds were not addressed.
Incorrect Oxygen Flow Rate
Penalty
Summary
The facility failed to provide the correct liters of oxygen per physician order for one resident. The resident was admitted with diagnoses including respiratory failure with hypoxia, kidney failure, and diabetes mellitus. A physician order dated 8/9/2024 directed the resident to receive oxygen at 2 liters per minute via nasal cannula continuously, and the oxygen therapy care plan indicated the resident received oxygen related to respiratory failure with hypoxia. The resident’s MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for all ADLs. During an observation at the resident’s bedside, the resident was lying in bed with the head of bed elevated. The oxygen concentrator was running and connected to a nasal cannula that was on the resident’s face but not in the resident’s nose, and the flow rate was set to 1 liter per minute. During a concurrent interview, the LVN checked the physician order and stated the resident should have been receiving 2 liters per minute. The LVN stated that not receiving the prescribed oxygen could cause the resident’s oxygen level to drop. The DON stated nurses must follow the doctor’s order when administering oxygen and that the resident could experience respiratory issues if the order is not followed.
Failure to Reassess and Administer Ordered Pain Medication
Penalty
Summary
Resident 74, who was admitted with diagnoses including osteoarthritis of the left knee, atrial fibrillation, protein calorie nutrition, and hypothyroidism, had intact cognition on the MDS dated 1/21/2026. During an interview, the resident stated she was not provided adequate pain relief after admission and reported that for three nights she was unable to get a good night sleep and was angry because her pain was not managed effectively. She stated that when she reported pain rated 8/10, she received Tylenol, which did not provide much relief, and that she did not receive her first dose of pain-relieving medication until 1/19/2026 at 2:15 a.m. The physician orders in the record included Acetaminophen 500 mg, two tablets by mouth every 8 hours for pain management for 5 days, and Oxycodone HCl 5 mg, 0.5 tablet by mouth every 6 hours as needed for moderate pain 4-7/10, as well as Oxycodone HCl 5 mg, one tablet by mouth every 6 hours as needed for severe pain 8-10/10. The EMAR showed Acetaminophen was administered from 1/16/2026 through 1/19/2026, but Oxycodone was not offered or administered on 1/16/2026, 1/17/2026, or 1/18/2026. The EMAR also did not show documented reassessment of pain after Acetaminophen was given. Nurses’ progress notes from 1/16/2026 through 1/18/2026 did not document follow-up pain evaluations after Acetaminophen administration. In interviews, LVN 3 and LVN 1 each stated they administered scheduled Acetaminophen but did not reassess the resident’s pain afterward. The DON stated licensed nurses are expected to follow medication orders, offer pain medications as ordered, and reassess pain after administering pain medication to ensure pain is relieved. The facility’s Pain Assessment and Management policy stated acute pain should be assessed every 30 to 60 minutes after onset and reassessed until relief is obtained.
Failure to Administer Ordered Epogen and Clarify Dialysis Medication Responsibility
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis-related care for a resident with ESRD and dependence on renal dialysis by not administering Epogen as ordered, not clarifying whether the facility or the dialysis center was responsible for giving the medication, and not communicating with the dialysis center about Epogen administration. The resident was readmitted with ESRD and diabetes, had intact cognition, and required substantial assistance with several activities of daily living. The resident’s care plan identified dialysis-related risks and included monitoring for complications of dialysis. The physician ordered Epogen 1 ml subcutaneously three times weekly on dialysis days, and the resident’s January 2026 MAR and administration notes showed multiple missed doses because the medication was unavailable. The record review also showed no documentation that the medication was administered at the dialysis center and no documentation that nursing staff contacted the pharmacy to request the medication. The pre- and post-dialysis assessment forms had blank sections where medications given at the dialysis center were to be recorded, and the forms indicated Epogen was never given there. During interviews, the resident stated she had not missed any dialysis appointments. The RNS confirmed the resident did not receive Epogen on multiple dialysis days and stated that not receiving Epogen could lead to anemia. The DON stated the physician order indicated the medication would be given in the facility, but the pharmacy believed it would be administered in the dialysis center. The DON further stated nursing staff should have clarified the order with the physician and pharmacy and confirmed with the dialysis center that the medication would be given there; the DON also stated the dialysis center reported the resident was receiving Mircera instead of Epogen.
Failure to Isolate Resident with ESBL
Penalty
Summary
The facility failed to ensure infection control practices were followed when Resident 60, who had a urine culture positive for ESBL and an order for contact isolation, was not isolated from other residents. Resident 60 was admitted and later readmitted with diagnoses including encephalopathy, hyperlipidemia, and chronic kidney disease, and the MDS indicated impaired cognition and substantial to maximal assistance with ADLs. Laboratory results showed ESBL in the urine, and the order summary indicated contact isolation precautions for ESBL. During the initial tour, Resident 60 was not in her room and was sharing a room with three other residents. Staff interviews confirmed that Resident 60 had been on the patio for activities with other residents while on contact isolation for ESBL of the urine. The LVN, IP nurse, and DON each stated that Resident 60 should have been isolated in a single room and not placed with other residents because ESBL required contact isolation and could be transmitted if proper precautions were not observed. The facility policy stated transmission-based precautions are initiated for a laboratory confirmed infection when the resident is at risk of transmitting the infection to other residents, including when cognitive deficits interfere with maintaining precautions.
Failure to Timely Report Suspected Abuse to Proper Authorities
Penalty
Summary
The facility failed to report an allegation of suspected abuse involving a resident within the time frame specified by facility policy. The incident involved a female resident with multiple medical conditions, including spinal stenosis, chronic kidney disease, and chronic lymphocytic leukemia in remission, who was dependent on staff for toileting and personal hygiene. During a shift, a Certified Nursing Assistant (CNA) observed that the resident did not want her family member (FM) to perform perineal care, but the FM insisted and proceeded to do so aggressively, causing the resident pain and distress. The resident verbally requested the FM to stop, but the FM refused, and the CNA noted redness and irritation in the perineal area, suspecting abuse. The CNA reported the incident to the Registered Nurse (RN), who attempted to report the suspected abuse to Adult Protective Services (APS) and the Ombudsman but was unable to reach them immediately. The RN subsequently reported the incident verbally and in writing to APS the following day and informed the Director of Nursing (DON). However, the RN was unfamiliar with the facility's reporting process and did not know the identity of the abuse coordinator, leading to further delays in proper notification. The Director of Social Services (DSS) and the Administrator were not immediately informed, and the police were not contacted as required by facility policy. A review of the facility's Abuse Prevention and Prohibition Program policy indicated that all staff are mandatory reporters and must report suspected abuse immediately, but no later than two hours after forming a suspicion, to the state survey agency, APS, law enforcement, and the Ombudsman. The policy also specifies that the Administrator or designee is responsible for reporting and that failure to report within the required time frames may result in disciplinary action. In this case, the facility did not adhere to its own policy, resulting in a delay in reporting the suspected abuse to the appropriate authorities.
Failure to Display Current Administrator's License
Penalty
Summary
The facility failed to display and provide a copy of the current Administrator's license as required by regulation. During an unannounced visit, surveyors observed that the license posted was for a former Administrator, and there was no license displayed for the current Administrator. The current Administrator, who had been employed for one month, stated in an interview that he did not have a copy of his license because it was mailed to the wrong address and he had no way to print another copy. He acknowledged awareness that the license should be posted from the first day of employment. Additionally, the Director of Medical Records confirmed that the facility did not have a policy regarding the Administrator's license.
Failure to Address Resident Grievances and Missing Property
Penalty
Summary
The facility failed to honor residents' rights to voice grievances and did not take appropriate corrective action regarding reports of missing personal property for two residents. One resident, who had an intact cognitive status and required moderate to maximal assistance with activities of daily living, reported that a certified nursing assistant accidentally sent his cell phone to the laundry with the bed linens, resulting in damage to the phone. This resident also reported multiple missing items, including clothing, shoes, and eyeglasses, and stated that repeated requests to speak with the social worker about these issues were ignored for several days. Review of the resident's medical chart revealed that no inventory list was created upon admission, as required by facility policy. Another resident, who was the roommate of the first, also reported missing several items of clothing and stated that he had been requesting to speak with the social worker for over a month without response. This resident expressed anger over the missing items and the lack of follow-up, which also affected his ability to attend follow-up medical appointments. Interviews with facility staff, including the Director of Social Services, Administrator, and Director of Nursing, revealed that they were not aware of the missing property or the residents' grievances, and that required inventory lists had not been completed for either resident upon admission. Facility policies reviewed indicated that staff are required to inventory and document residents' personal belongings upon admission and to promptly investigate any reports of lost or stolen property. However, the facility did not follow these procedures, as evidenced by the lack of inventory documentation and failure to investigate or address the residents' complaints about missing property.
Resident Elopement Due to Inadequate Supervision and Non-Functional Alarm System
Penalty
Summary
The facility failed to adequately monitor and supervise a resident, leading to an elopement incident. The resident, who was admitted with diagnoses including epilepsy, a cardiac pacemaker, and hypertension, was cognitively intact but required substantial assistance with activities of daily living. Despite having a history of alcohol abuse and withdrawal, which could increase the risk of elopement, the facility did not conduct an elopement assessment upon admission or include specific interventions in the resident's care plan to prevent elopement. On the day of the incident, the resident was last seen in the facility lobby by a CNA. The resident managed to leave the facility unsupervised through the main door, which was not properly monitored. The facility's alarm system on several exit doors was either non-functional or not activated, failing to alert staff of the resident's departure. The staff's response was delayed, and the resident was not found until the following day, highlighting a significant lapse in supervision and safety protocols. Interviews with facility staff revealed that the door alarms were not regularly checked for functionality, and there was no documented evidence of routine maintenance or testing. The facility's policies required daily testing of the alarm system and immediate reporting of any malfunctions, but these procedures were not followed. The lack of a functional alarm system and the absence of a specific care plan for the resident's elopement risk contributed to the resident's unsupervised exit and the subsequent search efforts by the facility staff.
Failure to Properly Waste Controlled Medication
Penalty
Summary
The facility failed to properly waste an Ativan 0.5 mg tablet according to its controlled narcotic protocol, resulting in an inaccurate medication count for a resident. The resident, who was admitted with multiple diagnoses including Parkinson's disease, COPD, epilepsy, and dementia, was prescribed Ativan 0.5 mg to be administered four times a day for anxiety. During a review, it was found that the medication count was incorrect, with 31 pills present instead of the expected 33. The licensed vocational nurse (LVN) admitted to giving one tablet that morning and failing to document it, as well as dropping another tablet during the count with an off-going nurse, which was not wasted as per protocol. The LVN later signed the medication count sheet and had another charge nurse co-sign it, but the waste was not properly documented or witnessed by two licensed nurses as required. The Director of Nursing confirmed that narcotic waste should be witnessed and signed by two licensed nurses, and the LVN should have reported the incident to the DON. The facility's policy and procedures for medication administration and discarding medications were not followed, leading to this deficiency in handling controlled substances.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 2, who required oxycodone-APAP for moderate to severe pain. Despite a physician's order for the medication, the facility did not administer it for 18 out of 54 days. Resident 2, who had a history of cervical disc disorder, non-Hodgkin lymphoma, and a rotator cuff tear, experienced significant pain levels ranging from 4/10 to 8/10 during this period. The resident reported frustration and an inability to participate in activities due to the unmanaged pain. The deficiency was attributed to the facility's failure to ensure the medication was available and administered as prescribed. The Licensed Vocational Nurse (LVN) confirmed that the pharmacy did not send the medication because they had not received authorization from the ordering physician. There was no documented evidence that the physician was informed about the medication shortage, and the facility did not follow up to ensure the authorization was completed. This oversight resulted in Resident 2 experiencing unnecessary pain and a lack of participation in activities. Interviews with the nursing staff, including the Registered Nurse Supervisor and the Director of Nursing, revealed that the facility did not adhere to its policy and procedures for pain management. The staff acknowledged that medications should be ordered before the current stock runs out and that the prescribing physician should be contacted immediately if there are issues with medication authorization. The facility's failure to administer the prescribed pain medication led to Resident 2 suffering from unmanaged pain, as confirmed by the Medication Administration Record and staff interviews.
Failure to Obtain and Maintain PASRR Screening for Resident
Penalty
Summary
The facility failed to ensure that a pre-admission screening Resident Review level I (PASRR) was obtained and maintained in the resident's chart for one of the sampled residents. This deficiency was identified during a review of the admission records and interviews with facility staff. Resident 61, who was admitted with diagnoses including bipolar disorder, dementia, and major depressive disorder, did not have a PASRR level I on file. The absence of this screening could potentially impact the appropriateness of care and services provided to the resident. Interviews with the Social Services Director (SSD) and the Admissions Director (AD) revealed a lack of awareness and adherence to the facility's policy regarding PASRR screenings. The SSD admitted to not being familiar with the PASRR process, while the AD confirmed that the PASRR should have been obtained from the hospital prior to admission. The Director of Nursing (DON) also acknowledged the missing PASRR and its importance in addressing the resident's mental health needs. The facility's policy mandates that all applicants be screened for serious mental disorders or intellectual disabilities, and a record of the prescreening should be maintained in the resident's medical chart.
Failure to Ensure Resident Wore Neck Brace as Ordered
Penalty
Summary
The facility failed to ensure that Resident 122 wore a neck brace at all times as per the physician's order. Resident 122 was admitted with a displaced fracture of the second cervical vertebra and had a care plan indicating the need to wear a cervical collar due to this condition. During an observation, it was noted that the resident was lying in bed without the neck brace, which was found next to the resident instead of being worn. This observation was made in the presence of a physical therapist and a registered nurse, both of whom acknowledged that the resident was supposed to wear the neck brace at all times to prevent further injury and pain. The facility's policy and procedures on cervical collars, dated January 25, 2022, stated that the purpose of the collar is to treat an acute injury or prevent potential cervical spine fracture or cord damage. The policy also indicated that the wearing schedule of the cervical collar is based on the physician's order. Despite these guidelines, the facility did not adhere to the physician's order for Resident 122, as evidenced by the resident not wearing the neck brace during the observation. This failure had the potential to cause further injury and pain to the resident.
Failure to Clean Bipap Machine as Required
Penalty
Summary
The facility failed to provide proper respiratory care for a resident by not cleaning the Bilevel Positive Airway Pressure (Bipap) machine as required. Resident 8, who was admitted with diagnoses including generalized muscle weakness, morbid obesity, and chronic respiratory failure, reported that the facility staff did not clean her Bipap machine daily, as per the physician's orders. The orders specified that the Bipap/CPAP filter should be washed with warm soapy water, rinsed, and air-dried daily, while the mask, tubing, humidifier container, and headgear should be cleaned weekly. During an observation, the Bipap machine was found on the nightstand next to the resident's bed, and the resident expressed frustration and nervousness about the lack of daily cleaning. Interviews with facility staff revealed a lack of proper training and documentation regarding the cleaning and operation of the Bipap machine. The Director of Staff Development (DSD) admitted that the last in-service on Bipap operation was conducted without a lesson plan or materials, and staff did not perform return demonstrations to assess competency. Licensed Vocational Nurses (LVNs) confirmed they had not received training on Bipap machine use and were unaware of the last cleaning date for Resident 8's machine. The facility's policy indicated that cleaning instructions should be obtained from the manufacturer, but this was not followed, leading to the potential risk of respiratory infection for the resident.
Deficiencies in Staff Competency and Certification
Penalty
Summary
The facility failed to ensure that staff were competent in operating and cleaning a Bilevel Positive Airway Pressure (Bipap) machine, which is crucial for residents with respiratory issues. Resident 8, who was admitted with conditions such as generalized muscle weakness, morbid obesity, and chronic respiratory failure, reported that the Bipap machine was not being cleaned daily, causing frustration and nervousness. The Director of Staff Development (DSD) admitted that there was no structured in-service training or materials available for staff on the operation and maintenance of the Bipap machine, and no return demonstrations were conducted to assess staff competency. Additionally, the facility did not ensure that five staff members, including a registered nurse supervisor, a licensed vocational nurse, and certified nursing assistants, had current Cardiopulmonary Resuscitation (CPR) certification. The Director of Nursing (DON) and DSD acknowledged that employee files were incomplete, lacking documentation of current CPR certification and annual competencies. Interviews with staff revealed a lack of training on the Bipap machine and CPR, with some staff unable to demonstrate basic CPR skills or knowledge of emergency procedures. The facility's policies and procedures indicated that only qualified and properly trained personnel should operate Bipap machines and that CPR certification was mandatory for key clinical staff. However, the facility failed to adhere to these policies, as evidenced by missing certifications and inadequate training. This lack of compliance had the potential to cause physical harm to residents, particularly those dependent on Bipap machines and in need of emergency CPR intervention.
Failure to Provide Functional Bed and Mattress
Penalty
Summary
The facility failed to provide a functional bed and a comfortable mattress for a resident, leading to significant discomfort and distress. The resident, who was admitted with conditions including generalized muscle weakness, morbid obesity, and chronic respiratory failure, required extensive assistance with daily activities. Despite having the cognitive capacity to understand and make decisions, the resident was unable to adjust the bed height, which was necessary for both comfort and care. The mattress was found to be worn out, with holes and covered with duct tape, and the bed was not operating properly. The resident reported the issue to the Maintenance Supervisor a week prior, but no action was taken to replace the bed or mattress. Observations confirmed the bed's malfunction and the poor condition of the mattress. Interviews with the Maintenance Supervisor and a Registered Nurse highlighted the potential risks of injury to staff and the resident, as well as the possibility of infection and bed sores due to the unclean and damaged mattress. The facility's policy required regular inspections and maintenance of beds, which was not adhered to in this case.
Failure to Complete PASRR Level II Assessment
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level II assessment for one resident, identified as Resident 27, as required by the PASRR Level I assessment. This oversight was discovered during a review of Resident 27's records, which indicated that the resident was admitted and readmitted with diagnoses of major depressive disorder and post-traumatic stress disorder (PTSD). The PASRR Level I screening conducted on January 25, 2024, indicated the need for a Level II mental health evaluation, which was not completed. The deficiency was further highlighted during an interview with the Director of Staff Development (DSD), who confirmed that the Level II assessment should have been completed promptly following a positive Level I screening. The DSD emphasized the importance of the Level II evaluation in developing appropriate care plans and interventions. The facility's policy, revised on June 22, 2023, mandates that a Level II resident review be completed within 40 calendar days of admission, which was not adhered to in this case.
Obstructed Room Entrance Poses Safety Hazard
Penalty
Summary
The facility failed to ensure a hazard and clutter-free environment for two residents, leading to a deficiency in maintaining a safe and accessible living space. During a facility tour, it was observed that the entrance to the shared room of two residents was obstructed by two wheelchairs, each containing boxes. One wheelchair held a facility supply of nasal cannulas, while the other contained personal belongings of one of the residents. This obstruction posed a safety and fire hazard, potentially delaying emergency access to the residents. Resident 17, who was cognitively intact and required assistance with certain activities of daily living, and Resident 46, who had severe cognitive impairment and was totally dependent on staff for care, were both affected by this deficiency. The facility's policy on providing a safe and homelike environment was not adhered to, as the cluttered entrance could impede prompt staff access in emergencies, as confirmed by a registered nurse during an interview.
Failure to Monitor and Report Signs of UTI in Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident who was incontinent of bowel and bladder. The resident, who had an indwelling catheter, was observed to have cloudy urine with clusters of sediments, which are signs of a urinary tract infection (UTI). Despite these observations, there was no change of condition noted or physician notification made by the staff, as confirmed by the Registered Nurse Supervisor during an interview. This oversight occurred even though the resident's care plan specifically required staff to monitor, record, and report signs and symptoms of a UTI, such as cloudiness and deepening of urine color. The resident, who was admitted and readmitted to the facility with diagnoses including obstructive and reflux uropathy, dementia, and generalized muscle weakness, was dependent on staff for activities of daily living. The facility's policy on catheter care, revised in September 2023, emphasized the importance of checking urine for unusual appearance to prevent catheter-associated urinary tract infections. However, the staff failed to adhere to this policy, resulting in a delay in addressing the resident's potential UTI, as evidenced by the physician's order for Ertapenem sodium only being received the day after the surveyor's observation.
Failure to Label Feeding Tube Syringe
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to prevent complications related to a gastrostomy tube. Specifically, the facility did not label the resident's tube feeding syringe with the date it was opened, which is a necessary step to prevent infection and contamination. This oversight was observed during a survey when the syringe was found hanging from the resident's feeding pole without a date label. The Registered Nurse Supervisor confirmed the deficiency, acknowledging that the syringe needed to be labeled to prevent potential infection. The resident involved in this deficiency was admitted with multiple diagnoses, including diabetes mellitus, cerebral infarction, and pulmonary embolism, and was dependent on staff for activities of daily living due to cognitive impairment. The facility's policy on administration set and tubing changes, revised in December 2024, outlines the need for aseptic procedures to prevent infections, including labeling devices added to tubing. The failure to adhere to this policy had the potential to cause a spread of infection, as noted by the Registered Nurse Supervisor.
Infection Control Deficiencies in Resident Care and Equipment Maintenance
Penalty
Summary
The facility failed to maintain proper infection control measures, leading to several deficiencies. During a facility tour, it was observed that resident rooms 15, 17, 22, 23, and 32 did not have toilets or sinks for handwashing, despite being under enhanced barrier precautions due to the risk of spreading multi-drug resistant organisms (MDROs). Certified nursing assistants (CNAs) were found to be improperly handling urinals and bedside commodes, using sinks in restrooms not designated for such purposes, and disposing of waste inappropriately. The facility's policy on bedside commode use was found lacking in specific cleaning instructions, contributing to the potential spread of infection. Additionally, the restroom located between certain rooms was used by staff and visitors, despite being intended for resident use only. This was confirmed through interviews and observations, where it was noted that the restroom lacked proper signage to indicate its intended use. Staff and family members were observed using the restroom sink to rinse urinals, which could lead to cross-contamination. The presence of a large garbage can in the shower room, used for disposing of dirty diapers and commode contents, further compromised the hygiene of the environment, as it was sometimes left in the shower room during resident showers. Resident 8, who required a Bipap machine for chronic respiratory failure, reported that the facility staff were not cleaning the machine daily as required. Interviews with staff revealed a lack of training and in-service education on the proper operation and cleaning of Bipap machines. The Director of Staff Development admitted to not having a lesson plan or materials for training staff on Bipap machine maintenance, and staff members confirmed they had not received adequate training. This oversight in staff education and adherence to cleaning protocols posed a risk of infection to the resident.
Deficiency in Staff Certification and Training
Penalty
Summary
The facility failed to ensure that a Restorative Nurse Assistant (RNA) was properly certified and trained before providing care to residents. During a record review and interview with the Director of Staff Development (DSD), it was discovered that the RNA's Certified Nursing Assistant (CNA) certification, Cardiopulmonary Resuscitation (CPR) certification, and RNA training certificate were missing from the employee file. The DSD acknowledged that these certifications were required for the RNA to perform their duties and stated that the RNA would be removed from their assignment until the necessary certification was obtained. The facility's policy and procedures on credentialing nursing service personnel require that nursing personnel present verification of certification prior to or upon employment and prohibit them from performing direct resident care services until certification is completed. The DSD expressed concern that the RNA's lack of proper training could potentially harm residents, as the RNA might not know the correct techniques for assisting residents with range of motion exercises, which are crucial for maintaining or increasing joint mobility and preventing contractures.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that 28 out of 32 rooms met the required 80 square feet per resident in multiple resident rooms. This deficiency was identified through observation, interview, and record review. The rooms in question included twenty-five 2-bed rooms, two 3-bed rooms, and one 4-bed room, all of which did not meet the minimum square footage requirements. Specifically, the 2-bed rooms were required to have at least 160 square feet, the 3-bed rooms at least 240 square feet, and the 4-bed room at least 320 square feet. However, the rooms were found to have less space per resident than required, with the 2-bed rooms having only 140 square feet, the 3-bed rooms having 196 and 217 square feet, and the 4-bed room having 294.5 square feet. During the initial tour, evaluators observed that the nursing staff had enough space to provide care, and privacy was maintained with curtains. Additionally, the rooms had direct access to the corridors. In a group interview with residents, no concerns were raised regarding the room sizes. Despite these observations, the facility's Client Accommodation Analysis confirmed the deficiency, and a room waiver request was submitted, indicating the facility's awareness of the issue.
Failure to Provide Hospice Information During Discharge
Penalty
Summary
The facility failed to follow the physician's orders by not providing a hospice agency for a resident upon discharge, as was ordered. This resulted in the resident receiving incomplete discharge information, causing confusion. The resident, who had severe cognitive impairments and required assistance with most Activities of Daily Living, was discharged to home with hospice care as per the discharge order. However, the family member of the resident reported that no hospice information or options were provided while the resident was still in the facility, leading to a confusing and tedious discharge process. The family member had to call the facility after the resident arrived home without instructions on how to initiate hospice services. The social worker admitted that the hospice information should have been provided during the discharge process for timely initiation of services. The facility administrator confirmed that the hospice information was given over the phone after the resident's discharge, but was unable to provide documentation or the specific date of verification. The facility's policy on transfer and discharge requires complete and appropriate discharge planning, which was not adhered to in this case.
Improper Medication Management for Discharged Residents
Penalty
Summary
The facility failed to properly manage medications for residents who were discharged or transferred, as observed in the cases of four residents. Medications were not returned or destroyed according to policy, resulting in multiple medications being left behind in the medication storage room. These medications were accessible to all staff with access to the room, which is against the facility's policy and procedure for medication management. The report details specific instances where medications were not handled correctly. For example, a resident discharged to another facility had medications left behind, and another resident transferred to a general acute care hospital also had medications that were not returned or destroyed. The facility's policy requires that medications left after a resident's discharge should be either returned to the pharmacy or destroyed, but this was not followed. Interviews with staff revealed a lack of adherence to the facility's medication destruction policy. A Licensed Vocational Nurse admitted that medications were not always destroyed nightly due to busy shifts, and a Registered Nurse Supervisor was unaware of the current status of residents whose medications were left behind. Additionally, the Director of Nursing was unsure of the facility's policy on medication destruction, indicating a lack of proper training or communication regarding medication management procedures.
Failure to Secure and Store Controlled Substances
Penalty
Summary
The facility failed to secure controlled substances belonging to a discharged resident, identified as Resident 4, according to its protocol. Resident 4, a male with a history of cancer-related diagnoses and pain, was admitted to the facility with physician orders for Hydromorphone and Morphine Sulfate ER, both classified as opioids and controlled substances. After leaving the facility against medical advice, Resident 4's medications were found unsecured in a box labeled 'patient's own medications store here' in the medication storage room. The Registered Nurse Supervisor was unaware of Resident 4's current status at the facility. Additionally, the facility did not store discontinued controlled substances per its policy. During an observation, the Director of Nursing (DON) was found to have a cabinet with a single lock containing multiple medication pill packs, including controlled substances, which should have been double-locked. The DON admitted to not knowing the last time the pharmacy had come to destroy these medications and had only recently contacted them for disposal. The facility's policy requires controlled substances to be stored in a double-locked compartment and monitored monthly by a consultant pharmacist. However, the pharmacist reported that the last waste of narcotics was conducted in August, and a scheduled waste in September did not occur due to the unavailability of the interim DON. This lapse in procedure resulted in controlled substances being easily accessible to staff with access to the medication storage room, posing a risk for drug diversion.
Medical Director Application Not Filed
Penalty
Summary
The facility failed to ensure that the Medical Director had filed an application with the State Licensing and Certification department's Centralized Applications Branch (CAB). This resulted in the Medical Director not being listed in the Electronic Licensing Management System (ELMS), which had the potential to affect resident care and medical oversight. On review of ELMS, it was found that the facility did not have a listed Medical Director. Interviews with the Administrative Assistant, a Licensed Vocational Nurse, and the Interim Director of Nursing confirmed the presence of a Medical Director, although the LVN did not know the name. The facility Administrator confirmed the Medical Director's name and stated that the application was being prepared for submission to CAB. The Medical Director was not part of the governing body but participated in Quality Assessment and Assurance meetings. The facility's job description for the Medical Director outlined responsibilities for guiding and overseeing resident care policies and procedures.
Failure to Provide Timely Transfer and Discharge Notification
Penalty
Summary
The facility failed to provide timely notification of a proposed transfer and discharge to a resident, as well as to the resident's representative and the State Long Term Care Ombudsman. This deficiency was identified during a review of the case of a resident who was admitted with conditions including hemiplegia, hemiparesis, PTSD, and major depressive disorder. The resident required significant assistance with activities of daily living and had moderate cognitive impairment. Despite these needs, the facility did not provide the required advance notice of the transfer, which was initiated following a physician's order to discharge the resident to another skilled nursing facility. The Social Services Director admitted to discussing the discharge with the resident only on the day of the transfer, without providing the necessary advance notice or notifying the Ombudsman. The facility's policy requires a 30-day notice for transfers or discharges unless specific urgent circumstances exist, none of which were applicable in this case. The lack of proper notification led to the resident experiencing confusion and distress, as they were informed of the transfer only an hour before it occurred.
Failure to Develop Individualized Discharge Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan with measurable objectives, timeframe, and interventions for a resident upon readmission. This deficiency was identified for a resident who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, post-traumatic stress disorder, and major depressive disorder. The resident had moderate cognitive impairment and required substantial to maximal assistance for activities of daily living. Despite these needs, the facility did not initiate a discharge care plan, which is crucial for ensuring a smooth and safe transition from the facility to a post-discharge setting. Interviews with the Social Services Director and the Director of Nursing confirmed the absence of a discharge care plan for the resident. The Social Services Director acknowledged the importance of a care plan in facilitating discharge goals, while the Director of Nursing admitted that discharge planning should begin upon admission. The facility's policy and procedure on care planning, revised in October 2022, mandates the development of a culturally competent and trauma-informed comprehensive care plan for each resident, including discharge plans as appropriate. The lack of a discharge care plan resulted in the resident feeling confused and anxious.
Failure to Protect Resident from Abuse Due to Inadequate Caregiver Screening and Supervision
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse, as outlined in their abuse prevention and prohibition program. The deficiency involved a caregiver, hired privately by another resident's family, who physically abused the resident by slapping them twice on the face. The facility did not implement its policies and procedures to screen and train caregivers, as neither of the two caregivers involved had undergone the required orientation or background checks. Additionally, the facility lacked complete identifiable and contact information for the caregivers. On the day of the incident, the resident was left alone on the patio with the caregiver, despite a verbal altercation being overheard by the Activities Director. The Activities Director failed to separate the caregiver from the resident and left the area, allowing the altercation to continue. The Guest Liaison also left the resident alone with the caregiver, who then moved the resident to a secluded area and committed the abuse. The facility's failure to ensure proper supervision and intervention contributed to the occurrence of the abuse. The resident involved had a history of cognitive impairment and was dependent on staff for various daily activities. The incident was witnessed by the Guest Liaison, who reported it to the Administrator, leading to police involvement. The facility's Director of Nursing admitted to not having documented evidence of background checks or orientation for the caregivers, acknowledging a lapse in following the facility's policies. This oversight and lack of proper procedures directly led to the resident being subjected to abuse.
Removal Plan
- The Caregiver for Resident 3 was removed until a background check, orientation, and abuse training could be completed.
- The facility's Nurse Consultant Director Registered Nurse conducted in-service to all schedule staff on types of abuse and screening, and abuse prevention, intervention, investigation, reporting and monitoring.
- The facility created a Caregiver Logbook which was placed at the receptionist desk, whereby all future caregivers will be directed by the receptionist to verify or complete a background check, abuse training, and orientation.
- Social Services shall conduct room rounds 5 days a week, at least 10 residents a day to monitor residents for concerns, grievances, or allegations of abuse.
- AD1 was provided in-service by the Nurse Consultant Director RN by phone regarding abuse prevention and abuse policies including not to leave a resident alone after hearing a verbal altercation and must separate caregiver from resident.
- The Nurse Consultant RN in serviced AD1 regarding not leaving a resident alone during resident-to-resident altercation.
- The Nurse Consultant RN in-serviced to all working and on-coming staff regarding abuse prevention, review of abuse policy, and the caregiver/visitor log.
- An audit was performed by Medical Records Director for all residents to identify any residents utilizing caregivers - none were found.
- The Director of Staff Development (DSD) will provide caregiver training for future caregivers and will be on-going.
- GL1 was in serviced by phone regarding not leaving a resident alone during resident-to-resident altercation.
- The Medical Records Director (MRD) will audit monthly compliance of Caregiver Logbook and Visitor check in and report to the ADM all findings.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate and report an allegation of physical abuse involving a resident and a caregiver to the Department of Public Health, Ombudsman, and local law enforcement within the required timeframe. The incident involved a resident with cognitive impairment and dementia, who was dependent on staff for various activities and used a wheelchair for mobility. The resident was allegedly slapped by another resident's caregiver during a heated conversation in Farsi, which was witnessed by a guest liaison. The guest liaison observed the altercation and reported it to the administrator, who instructed her to inform the social worker. The social worker subsequently contacted the police, who arrived at the facility shortly after. However, the facility did not report the incident to the State Survey Agency within the mandated two-hour window, as the fax confirmation log indicated the report was sent over four hours after the incident occurred. The facility's policy and procedures on abuse prevention and prohibition require immediate reporting of such allegations, but this was not adhered to, resulting in a delay in communication and investigation. The administrator acknowledged the requirement for timely reporting to prevent noncompliance and ensure the safety of the residents involved.
Lack of Physician Documentation for Resident Discharge
Penalty
Summary
The facility failed to provide necessary physician documentation to support a facility-initiated discharge for a resident, identified as Resident 1. This deficiency was identified during an interview and record review, where it was found that the facility did not have the attending physician's documentation to justify the discharge. The resident, a male with a history of cerebral infarction, hemiplegia, hemiparesis, and other conditions, was issued a 30-day notice of transfer or discharge due to alleged physical aggression towards staff, which was claimed to create an unsafe environment. The Director of Social Services (DSS) acknowledged that the attending physician was informed of the resident's behavior but did not attend the Interdisciplinary Team (IDT) Care Conference. The DSS was uncertain if the physician agreed with the discharge decision and could not provide any supporting documentation from the physician. Furthermore, the facility's Administrator admitted that although there was an order from the physician indicating the resident could be transferred to a lower level of care, the facility did not have the physician assess the resident or have a psychologist evaluate the resident's behavior before initiating the discharge. The facility's policy on transfer and discharge requires written documentation from the attending physician to support such actions, especially when the safety of individuals in the facility is claimed to be endangered. The resident's appeal against the discharge was granted due to the facility's failure to provide the necessary physician documentation. The facility's policy also outlines that residents should not be transferred or discharged while an appeal is pending unless it is documented that their presence endangers health or safety, which was not adequately documented in this case.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident, which was not communicated to the abuse coordinator or the state agency. The incident involved a male resident with a history of hemiplegia, shoulder dislocation, falls, hypertension, and polyneuropathy, who was admitted to the facility in July 2024. The resident, with mildly impaired cognition, alleged that a certified nursing assistant (CNA) attempted to hit him after a disagreement over the delivery of butter during breakfast. The resident felt threatened and angry, although no physical contact occurred. The incident was witnessed by an unidentified staff member who dismissed the resident's claims. The CNA involved in the incident denied the allegations, stating that the butter was placed on the table without any aggressive behavior. The CNA reported the resident's accusations to a Licensed Vocational Nurse (LVN), who checked the breakfast tray and found the food untouched. The LVN suggested that the resident might have been offended by the CNA's tone but did not believe any abuse occurred. The LVN reassigned the CNA but failed to report the incident to the Assistant Director of Nursing (ADON) or the Administrator, who is the designated abuse coordinator. The facility's policy mandates immediate reporting of abuse allegations to the supervisor and the Administrator. However, the LVN did not follow this protocol, and the incident was not reported until a surveyor's interview days later. The Administrator confirmed that the incident should have been reported immediately to allow for proper investigation and notification to authorities. The facility's policy emphasizes mandatory reporting and non-retaliation for staff who report abuse in good faith.
Failure to Implement Proper Discharge Plan with Hospice Care
Penalty
Summary
The facility failed to develop and implement a discharge plan that included visits by an operating hospice agency for a resident with a terminal condition. The resident, who had diagnoses including malignant neoplasm of the left breast, type II diabetes mellitus, and major depressive disorder, was discharged to home with hospice care. However, the facility did not provide the resident's family member with written information about the hospice agency, leading to confusion and difficulty in finding information about the agency. The family member later discovered that the hospice agency was illegible and reported this to the facility administrator. The Social Services Director (SSD) admitted to initiating the referral for the hospice agency through an outside marketer without having a contract agreement or detailed documentation of the services to be provided. The SSD also failed to document the discharge follow-up in the resident's medical record. This lack of proper discharge planning and communication resulted in the resident not receiving the necessary physical, emotional, social, and spiritual support when nearing the end of life, as required by the facility's policy and procedure on transfer and discharge.
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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 Santa Monica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Shepherd Health Care Center Of Santa Monica | 0.6 mi | ★★★★★ | 25 | 0 |
| Beachwood Post-acute & Rehab | 0.6 mi | ★★★★★ | 3 | 0 |
| Ocean Pointe Healthcare Center | 1.2 mi | ★★★★★ | 32 | 0 |
| Berkley West Healthcare Center | 1.2 mi | ★★★★★ | 14 | 0 |
| Pacific Post Acute | 1.2 mi | ★★★★★ | 15 | 0 |
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