Good Shepherd Health Care Center Of Santa Monica
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 1131 Arizona Ave., Santa Monica, California 90401
- CMS Provider Number
- 555061
- Inspections on file
- 22
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Good Shepherd Health Care Center Of Santa Monica during CMS and state inspections, most recent first.
A resident in an LTC facility developed a stage 1 pressure ulcer that progressed to stage 4 due to inadequate care and failure to update care plans. Despite being at risk for skin breakdown, the facility did not implement effective interventions to address the resident's non-compliance with turning and repositioning. The care plans remained unchanged as the ulcer worsened, leading to severe tissue damage requiring debridement.
The facility failed to ensure kitchen staff were trained and competent in meeting residents' nutritional needs, particularly for those on puree diets. Staff did not follow recipes or portion sizes, serving puree scrambled eggs instead of the intended ham and potato casserole, leading to potential nutritional deficiencies. Additionally, the facility's freezer was found to be unsanitary, posing a risk of foodborne illness.
The facility failed to properly prepare and serve meals, affecting both regular and puree diets. The ham and potato casserole was not cut to the specified size and lacked garnish, while puree diet residents received dry scrambled eggs instead of the intended casserole. Additionally, puree wheat toast and raisin bran were too sticky, failing consistency tests. These deficiencies could lead to poor food intake and weight loss.
The facility failed to maintain safe food storage and preparation practices, with issues such as improper freezer temperatures, unsanitary kitchen equipment, and damaged utensils. Turkey was stored incorrectly, and various kitchen surfaces were not cleaned properly, leading to potential cross-contamination. Additionally, expired food was found in the resident's refrigerator, and staff used personal cellphones in the kitchen.
The facility failed to properly dispose of garbage by not covering a dumpster and maintaining cleanliness in the trash area, potentially attracting pests and spreading infection among residents. Interviews with staff confirmed the importance of keeping dumpsters closed and the area clean, as per facility policies and the Food Code 2017.
The facility did not submit Payroll Based Journal (PBJ) data to CMS for a required quarter in 2023, missing the deadline for the first fiscal quarter. The Director of Staff and Development/Infection Preventionist Nurse stated that the corporate office failed to complete the submission properly. Facility policies require quarterly submissions, and CMS guidelines stress the importance of timely and accurate data.
The facility did not deliver mail to residents on Saturdays, as confirmed by several residents and staff. Mail delivered by the post office on weekends was held until Monday for sorting and delivery by Social Services, contrary to the facility's policy on resident rights.
The facility failed to manage pain effectively for two residents. One resident did not have a lidocaine patch removed as ordered, while another missed multiple doses of Buprenorphine due to pharmacy delays. Interviews confirmed severe pain levels and inadequate medication administration, highlighting a failure to follow physician orders and ensure timely delivery.
The facility failed to follow the prescribed puree menu and portion sizes for residents on a puree diet. Instead of serving the pureed ham and potato casserole, staff served plain pureed scrambled eggs, which lacked essential nutrients. Additionally, incorrect portion sizes were used, potentially depriving residents of necessary calories and nutrients. A resident reported issues with portion sizes, indicating insufficient food on previous occasions.
The facility failed to prepare puree foods to meet IDDSI Level 4 requirements for residents with swallowing difficulties. Observations showed that puree eggs were too dry, and puree bread and cereals were too sticky, failing the spoon tilt test. This posed a risk of aspiration and choking for residents on this diet.
The facility did not meet the required room size of 80 square feet per resident in double occupancy rooms and 100 square feet in single rooms, affecting 23 out of 24 rooms. Despite this, observations showed no issues with privacy or care, and residents reported no concerns. The facility had requested a waiver for the non-compliant rooms.
A facility failed to obtain proper consent for the use of bilateral bed siderails as a restraint for a resident with a history of falls and moderate cognitive impairment. The resident was observed with siderails up, but there was no physician order or complete consent form. Staff interviews indicated the siderails were used for mobility and repositioning, although the resident could not use them effectively. This violated the resident's rights to respect and dignity.
A facility failed to ensure a resident was free from physical restraints by using bilateral bed siderails without a physician's order. The resident, with chronic kidney disease and pressure ulcers, was observed with siderails up, despite needing assistance for daily activities and having impaired cognitive skills. Staff interviews revealed the siderails were used to prevent falls, contrary to facility policy, which requires a physician's order for such use.
A resident with cognitive impairment and mobility limitations was found with an unexplained injury, but the LTC facility failed to report the incident to the state agency as required by their policy. The resident, who was non-verbal and required assistance for daily activities, was discovered hanging from the side of her bed with an open ecchymosis on her arm. The facility's failure to report the incident delayed an inspection by the Department of Public Health.
A facility failed to maintain a resident's dignity by not covering their urinary catheter drainage bag, as observed during a survey. The resident, who required maximal assistance for daily activities and had intact cognitive skills, was seen with an uncovered catheter bag in a shared room. The facility's policy required such bags to be covered to protect resident privacy, a standard confirmed by both an LVN and the DON.
A resident in an LTC facility reported missing packages and receiving opened mail, leading to feelings of anger. The facility's Social Service Director confirmed that residents did not receive mail on weekends, and the Director of Nursing was unaware of these issues. The facility's policy emphasized residents' rights to access mail and be free from misappropriation of property.
A resident with chronic kidney disease and weakness did not have a handroll applied to her right hand as ordered, despite needing moderate to maximum assistance with daily activities. Observations showed the handroll was only applied to the left hand. The RNA failed to report or document the resident's refusal to wear the right handroll, and the LVN was unaware of any refusals, risking the resident's hand becoming contracted.
A resident with an indwelling urinary catheter was at risk of infection due to improper placement of the Foley catheter bag above the bladder level, contrary to facility policy. The resident expressed concern, and both an LVN and the DON confirmed the incorrect placement, which hindered proper urine drainage.
A facility failed to provide necessary respiratory care for a resident with COPD by not ensuring a physician's order for oxygen therapy and not maintaining the humidifier as per policy. The resident was observed using an oxygen concentrator with an empty humidifier bottle, and no physician's order was found for the therapy. The DON confirmed the humidifier should be replaced weekly and as needed, and the facility's policy required a physician's order and sufficient water in the humidifier.
A facility failed to ensure proper oversight of Food and Nutrition Services when a resident with chronic kidney disease and pressure ulcers experienced significant weight loss without a comprehensive care plan. The RD provided recommendations but did not develop a care plan, citing time constraints. The DS did not act on the RD's notes or contact the physician, and the DON confirmed the DS lacked the credentials to perform RD duties. The RD's job responsibilities included reviewing care plans, which were not fulfilled, leading to the deficiency.
A resident reported feeling very cold in their room, which was observed to be below the facility's policy range for comfortable temperatures. The Maintenance Supervisor admitted to incomplete temperature logs and uncertainty about the last repair of the heating system. The Director of Nursing acknowledged that cold temperatures could make residents sick and uncomfortable.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to the development and progression of a pressure injury. The resident, who was admitted with conditions including paraplegia and polyneuropathy, was identified as at risk for skin breakdown due to non-compliance with turning and repositioning. Despite having a care plan in place, the facility did not implement effective interventions to address the resident's non-compliance, resulting in the development of a stage 1 pressure injury on the coccyx, which progressed to a stage 4 pressure injury within 16 days. The care plans for the resident's pressure injuries were not updated with new interventions as the condition worsened. The interventions remained the same from stage 1 through stage 4, despite the resident's refusal to comply with turning and repositioning. The facility's staff, including a Licensed Vocational Nurse, acknowledged that the care plans should have been revised with individualized interventions to address the resident's non-compliance and prevent the worsening of the pressure injury. The facility's policies and procedures required ongoing review and updating of care plans to ensure they were effective in meeting the resident's needs. However, the facility did not adhere to these policies, resulting in the resident's pressure injury progressing to a stage 4 with necrosis of muscle and bone, requiring debridement. The Director of Nursing confirmed that the care plans were not individualized or updated as required, contributing to the deficiency in care.
Inadequate Training and Sanitation in Kitchen
Penalty
Summary
The facility failed to ensure that kitchen staff were adequately trained and competent in meeting the nutritional needs of residents, particularly those on puree diets. Observations revealed that staff did not follow the recipe for puree ham and potato casserole, instead serving puree scrambled eggs, which lacked the necessary protein and nutrients. The Dietary Supervisor confirmed that the puree scrambled eggs did not provide the same nutritional value as the intended casserole, potentially leading to weight loss among residents. Additionally, the staff used incorrect portion sizes for puree eggs, serving two ounces instead of the required three ounces, further contributing to inadequate nutrition. Interviews with staff indicated a lack of understanding and adherence to recipes and portion sizes. One staff member admitted to not preparing the puree ham and potato casserole due to some residents' dietary restrictions and preferences, but acknowledged that this decision could affect the taste and nutritional content of the food. The Dietary Supervisor had previously provided in-service training on reading spreadsheets and preparing puree food, but the staff did not follow these guidelines on the day of observation. Furthermore, the facility's freezer was found to have dust and food residue, indicating poor sanitation practices. A staff member acknowledged the presence of dirt and debris but was unaware of the potential consequences for residents. The facility's policies and procedures required routine cleaning of refrigerator equipment, but this was not adhered to, posing a risk of foodborne illness. The competency test for kitchen staff did not include questions on following menus, spreadsheets, and recipes, highlighting a gap in training and oversight.
Deficiencies in Food Preparation and Presentation
Penalty
Summary
The facility failed to prepare and serve food in a manner that conserved flavor and appearance, as observed during a breakfast service. The ham and potato breakfast casserole, intended for residents on a regular diet, was served using a scoop instead of being cut to the specified portion size of 2 1/2 x 2 inches. It was also served in a bowl rather than on a plate, and lacked the parsley garnish that was supposed to enhance its presentation. The Dietary Supervisor noted that the presentation was unappetizing and could lead to residents not eating the meal, potentially resulting in weight loss. For residents on a puree diet, the facility did not follow the prescribed menu, which called for a puree ham and potato breakfast casserole. Instead, residents received puree scrambled eggs, which were described as too dry. The Dietary Supervisor acknowledged that the puree scrambled eggs lacked the nutritional components of the intended casserole, such as ham, potatoes, onions, and mustard, which could affect the taste and lead to poor food intake and potential weight loss. Additionally, the puree wheat toast and puree raisin bran were found to be too sticky, failing the spoon tilt test, which assesses the cohesiveness of pureed foods. The Dietary Supervisor indicated that the puree items did not meet the required consistency standards, making them unappetizing and potentially leading to poor food intake and weight loss. The facility's policies and procedures, as well as standardized recipes, were not adhered to, resulting in these deficiencies.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. The reach-in freezer was found to have fluctuating temperatures, ranging from 10 to 52 degrees Fahrenheit, instead of the required 0 degrees Fahrenheit, which is necessary to ensure food items remain frozen for infection control. Additionally, turkey was improperly stored on the bottom of beef without trays in between, violating the facility's policy on meat storage hierarchy, which could lead to cross-contamination. The kitchen was also found to have multiple cleanliness issues. Food preparation surfaces and kitchen equipment, including the reach-in refrigerator, ice machine, and juice machine racks, were not cleaned and sanitized properly. Observations revealed dirt, dust, and food debris on various equipment, such as the knife storage box, mixer, and scoop tray. The facility's policies and procedures were not followed, as these areas were supposed to be cleaned daily and deep cleaned weekly to prevent bacterial growth and cross-contamination. Furthermore, the facility used utensils and kitchen equipment that were damaged, including chopping boards with scratches, trays with cracks and chips, and a can opener blade with a chip. These conditions made it difficult to clean the surfaces properly, increasing the risk of bacterial growth and cross-contamination. Additionally, staff were observed using personal cellphones in the kitchen, and dented cans were stored with non-dented cans, both of which could lead to contamination. Expired yogurt and juice were also found in the resident's refrigerator, which could result in foodborne illness if consumed.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring that one of the two black dumpsters was completely covered and by not maintaining the cleanliness of the surrounding area. During an observation, it was noted that the dumpster was overflowing with trash and not fully closed, which could potentially attract pests and spread infection among the 46 residents of the facility. Interviews with the Dietary Supervisor and Maintenance Supervisor confirmed that the dumpster should always be closed and not overflowing, as this could attract pests and lead to foodborne illnesses. The facility's policies and procedures, as well as the Food Code 2017, require that garbage and trash cans be inspected daily to ensure no debris is on the ground and that lids are closed. The Maintenance Supervisor acknowledged that the trash area should be cleaned daily, but it was not done on the day of the observation. The failure to maintain the cleanliness of the trash area and ensure dumpsters are properly covered and not overflowing is a direct violation of these guidelines, posing a risk of attracting rodents and potentially causing illness among residents.
Failure to Submit PBJ Data for Required Quarter
Penalty
Summary
The facility failed to submit their Payroll Based Journal (PBJ) data to the Centers for Medicare and Medicaid Services (CMS) for one of the required quarters in 2023. Specifically, the facility did not submit the PBJ data for the first fiscal quarter, which was due on February 14, 2024. This deficiency was identified through a review of the facility's Certification and Survey Provider Enhanced Reporting system (CASPER), which showed no PBJ data submission from October 1, 2023, to December 1, 2023. Additionally, a review of the CMS Staffing Data Report confirmed the absence of data submission for the quarter. During an interview, the Director of Staff and Development/Infection Preventionist Nurse (DSD/IP) revealed that the PBJ reporting for the first quarter of 2024 was supposed to be completed by the facility's corporate office but was not done properly and was not submitted to CMS. The facility's policy and procedure documents indicated that direct staffing information should be submitted to the CMS payroll-based journal system at least once a quarter, with specific deadlines outlined. The CMS PBJ Policy Manual also emphasized the importance of timely and accurate data submission, noting that noncompliance could lead to enforcement actions by CMS.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents had reasonable access to their mail, as evidenced by the lack of mail delivery on Saturdays. During a resident council meeting, several residents, including Residents 11, 30, 33, and 41, confirmed that they did not receive mail on Saturdays. Resident 33 specifically mentioned that Social Services delivered mail only from Monday through Friday. The Social Services Director (SSD) corroborated this, stating that mail delivered by the post office on weekends was held until Monday for sorting and delivery. The Director of Nursing (DON) also confirmed that mail delivery occurred only on weekdays. This practice was contrary to the facility's policy on resident rights, which indicated that residents have the right to communication and access to services both inside and outside the facility.
Deficient Pain Management for Two Residents
Penalty
Summary
The facility failed to manage pain effectively for two residents, Resident 12 and Resident 42, as observed through various deficiencies in medication administration. For Resident 12, the facility did not adhere to the physician's order to remove a lidocaine patch after 12 hours of application. The patch was applied at 9:22 AM and was supposed to be removed by 9 PM the same day, but it was not removed until 9:36 PM. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the physician's order was not followed, resulting in inadequate pain management for Resident 12. Resident 42 experienced multiple instances where the prescribed pain medication, Buprenorphine HCI, was not administered as ordered. The resident missed a total of 45 doses over several periods in November and December due to the medication not being available on hand and delays in pharmacy delivery. Interviews with the resident and nursing staff revealed that the resident experienced severe pain levels, reaching 10/10, when the medication was not administered. The Director of Nursing confirmed that the pharmacy was expected to deliver medications promptly and that the nursing staff should have followed up to ensure the availability of the pain medication. The facility's policy on administering pain medications requires staff to administer medications as ordered and to report any adverse consequences. However, the failure to follow these procedures resulted in inadequate pain control for both residents. The deficiencies in pain management were identified through observations, interviews, and record reviews, highlighting the facility's failure to adhere to physician orders and ensure timely medication delivery.
Failure to Follow Puree Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to the prescribed puree menu for residents on a puree diet, as observed on December 28, 2024. Instead of serving the pureed ham and potato casserole as indicated in the nutritional spreadsheet, staff served plain pureed scrambled eggs. The Dietary Supervisor confirmed that the puree scrambled eggs did not provide the same nutritional value as the casserole, lacking essential ingredients like ham, potatoes, onions, and mustard. This deviation from the menu could potentially lead to inadequate protein and carbohydrate intake for residents on a puree diet. Additionally, the facility did not follow the correct portion sizes for puree scrambled eggs. Staff used a #16 scoop, which measures 2 ounces, instead of the #12 scoop, which measures 3 ounces, as specified in the spreadsheet. This resulted in smaller portion sizes than required, potentially depriving residents of the necessary calories and nutrients. Resident 21, who was on a renal, no added salt, consistent carbohydrate diet, and required double portions for breakfast, reported issues with portion sizes, indicating that he received insufficient food on previous occasions. The facility's policies and procedures, including those for food preparation, standardized recipes, and portion control, were not followed. The policies clearly outlined the need for using approved recipes and specific portion control equipment to ensure residents receive the correct portion sizes. The failure to adhere to these guidelines and the menu specifications could lead to malnutrition and weight loss among residents, as they may not receive the necessary nutrients and calories.
Failure to Provide Properly Prepared Puree Diet
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs for residents on a puree diet, specifically those requiring IDDSI Level 4 consistency. Observations revealed that puree eggs were too dry, and both puree bread and puree bran cereals were too sticky, failing the spoon tilt test, which is used to assess the stickiness and cohesiveness of food. This deficiency was identified during a review of the facility's daily menu and through direct observation and testing by the Dietary Supervisor, who confirmed that the food did not meet the required smooth, pudding-like consistency necessary for residents with swallowing difficulties. The facility's policies and procedures, as well as the diet manual, specify that pureed foods should be smooth, free of lumps, and not sticky, aligning with IDDSI Level 4 requirements. However, the food items served did not adhere to these guidelines, posing a risk of aspiration and choking for residents on this diet. The deficiency was noted for 8 out of 46 residents on the puree/IDDSI Level 4 diet, highlighting a significant lapse in ensuring the safety and nutritional adequacy of meals provided to residents with specific dietary needs.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to meet the regulatory requirement of providing at least 80 square feet per resident in double occupancy rooms and 100 square feet in single occupancy rooms. Out of 24 resident rooms, 23 did not meet the required space per resident, with most rooms providing only 69.35 square feet per resident. One room even accommodated three residents, offering only 50.25 square feet per resident. This deficiency was identified through a review of the facility's room waiver letter and client accommodations analysis form, which confirmed the inadequate space allocation. Despite the deficiency, observations during the annual recertification survey indicated no noted concerns with privacy, nursing care, or safety for the residents. Residents interviewed, including those residing in rooms with waivers, denied having any issues with the care received. The Director of Nursing confirmed that the facility had requested a continuation of the waiver for the rooms that did not meet the size requirements. The facility's policy, reviewed earlier in the year, stated that bedrooms should measure at least 80 square feet per resident in double rooms and 100 square feet in single rooms.
Failure to Obtain Consent for Siderail Use as Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraint by not completing the necessary consent for the use of bilateral bed siderails. The resident, who had a history of falls and was moderately cognitively impaired, was observed with bilateral siderails up on multiple occasions. Despite the siderails being used to prevent falls, there was no physician order for their use, and the consent form in the resident's chart was incomplete, lacking the resident's name and date of signing. Interviews with staff, including CNAs and the Director of Nursing, revealed that the siderails were intended for mobility and repositioning, although the resident was unable to use them for these purposes due to limited upper extremity strength. The facility's policy required consent for the use of siderails as restraints, which was not properly obtained in this case, leading to a violation of the resident's rights to be treated with respect and dignity.
Improper Use of Bed Siderails as Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints by not having a physician's order for the use of bilateral bed siderails. The resident, who was admitted with chronic kidney disease and pressure ulcers, was observed on multiple occasions with the siderails up, despite having moderately impaired cognitive skills and requiring moderate assistance for activities of daily living. The facility's policy stated that siderails are considered restraints if used to limit a resident's freedom of movement without a physician's order. Interviews with staff, including CNAs and an LVN, revealed that the siderails were used to prevent the resident from falling, despite the resident's inability to use them for mobility or repositioning due to lack of upper extremity strength. The Director of Nursing confirmed that siderails should not be used as restraints without a physician's order and consent. The facility's policy emphasized that siderails should only be used as mobility aids and not as restraints unless necessary for medical symptoms, highlighting the deficiency in following proper procedures for siderail use.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to adhere to its policy regarding the reporting of an injury of unknown source for a resident, leading to a delay in an onsite inspection by the Department of Public Health. The resident, who was non-verbal and required assistance for daily activities, was found with an open ecchymosis on her outer right arm after being discovered hanging from the side of her bed. The incident was unwitnessed, and the resident was unable to explain how she ended up in that position. The resident had a history of chronic kidney disease and pressure ulcers and was moderately impaired cognitively, requiring moderate assistance from staff for activities of daily living. Despite the presence of an unexplained injury, the facility did not report the incident to the State Agency as required by their policy. Interviews with staff, including a Licensed Vocational Nurse and a Certified Nursing Assistant, confirmed that the resident could not move independently and required staff assistance for repositioning and feeding. The facility's policy on investigating injuries and abuse prevention mandates reporting such incidents to the state agency and other relevant authorities within 24 hours. However, the Director of Nursing acknowledged that the incident was not reported, which is a violation of the facility's procedures. This oversight had the potential to place residents at further risk for injuries due to the lack of timely investigation and intervention.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to protect the privacy and dignity of a resident by not ensuring that the resident's indwelling urinary catheter drainage bag was covered. This deficiency was observed during a survey when Resident 97 was seen with an uncovered foley catheter drainage bag while sharing a room with another resident. The lack of a privacy cover for the catheter bag was noted during an observation on December 27, 2024, at 6:34 p.m. Resident 97 was admitted to the facility with diagnoses including acute kidney failure and benign prostatic hyperplasia. The resident's cognitive skills for daily decisions were intact, and they required maximal assistance for activities of daily living. The facility's policy on dignity, dated January 31, 2024, explicitly stated that urinary catheter bags should be covered to maintain resident dignity. Interviews with the LVN and the DON confirmed that the absence of a privacy cover was a violation of the resident's privacy and dignity.
Failure to Deliver Resident Mail and Packages
Penalty
Summary
The facility failed to allow a resident to retain his personal possessions, specifically his mail and packages, which led to the resident feeling angry. The resident, who had been in the facility for eight months, reported missing two packages, one of which was a Christmas gift from a friend. The resident was able to show a photo indicating the package was delivered to the nurse's station, but he did not receive it. Additionally, the resident mentioned receiving opened mail approximately three months ago and not receiving mail on weekends. The resident's medical records indicated he had intact cognition and the capacity to make decisions. Interviews with facility staff revealed that the Social Service Director (SSD) was responsible for sorting and delivering mail, but residents did not receive mail on weekends due to staff not wanting to be responsible for business office mail. The SSD acknowledged that residents should receive their mail unopened and on weekends, and that failure to do so could cause residents to feel sad and angry. The Director of Nursing (DON) was unaware of the issues with mail delivery and acknowledged that such failures could lead to resident frustration and sadness. The facility's policy on resident rights emphasized the right to be free from misappropriation of property and to have access to mail.
Failure to Apply Handroll to Resident's Right Hand
Penalty
Summary
The facility failed to apply a handroll to the right hand of Resident 43, who was readmitted with diagnoses including weakness and chronic kidney disease. The resident's Minimum Data Set indicated a need for moderate to maximum assistance with various activities of daily living. An order summary report specified that bilateral handrolls should be applied for 4-6 hours per day as tolerated. However, observations on multiple occasions revealed that the handroll was consistently applied only to the left hand, not the right. Resident 43 expressed a desire to have the handroll applied to the right hand to prevent it from becoming contracted like the left hand. The Restorative Nurse Assistant (RNA) admitted to not applying the right handroll consistently and failing to report or document the resident's refusal to wear it. The Licensed Vocational Nurse (LVN) was unaware of any refusals and acknowledged the risk of the resident's hand becoming contracted if the handroll was not used as ordered. The facility's job description for the RNA emphasized the importance of implementing restorative care and accurately documenting activities, which was not adhered to in this case.
Improper Foley Catheter Placement Leads to Deficiency
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, admitted with acute kidney failure and benign prostatic hyperplasia, required maximal assistance for activities of daily living and had intact cognitive skills. A physician had ordered monitoring of the resident's Foley catheter every shift. However, during an observation, the resident's Foley catheter was found hanging on a moveable bedside rail above the level of the bladder, with the tubing twisted and urine not flowing into the drainage bag. The resident expressed concern about the catheter's placement, fearing it might be pulled out. Licensed Vocational Nurse (LVN) confirmed the improper placement of the Foley catheter bag, noting it was too high and not allowing urine to drain properly. The Director of Nursing (DON) also acknowledged that the drainage bag should be positioned below the bladder to prevent infection. The facility's policy on catheter care clearly stated that the urinary drainage bag must be positioned lower than the bladder to prevent backflow of urine, which was not adhered to in this instance.
Failure to Ensure Physician's Order and Maintain Humidifier for Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not ensuring a physician's order was in place for oxygen therapy and not maintaining the resident's humidifier according to the facility's policy. The resident, who had been admitted with chronic obstructive pulmonary disease (COPD), atrial fibrillation, and chronic kidney disease, was observed using an oxygen concentrator at 2 liters per minute with a nasal cannula and humidifier. However, the humidifier bottle was found empty, and there was no physician's order for the oxygen therapy, which was confirmed by a Licensed Vocational Nurse (LVN) during an observation. The Director of Nursing (DON) stated that the humidifier should be replaced weekly and as needed, and that an empty humidifier would not provide the necessary humidification. The facility's policy on oxygen therapy required verification of a physician's order and ensuring the humidifier had enough water to bubble as oxygen flowed through. The lack of a physician's order and the empty humidifier bottle indicated a failure to adhere to these protocols, potentially compromising the resident's respiratory care.
Inadequate Oversight of Nutrition Services Leads to Deficiency
Penalty
Summary
The facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel, specifically when the Registered Dietitian (RD) did not conduct a comprehensive care plan for a resident who experienced significant weight loss. The resident, who had chronic kidney disease and pressure ulcers, was readmitted to the facility and later experienced a 7-pound weight loss over 30 days. Despite the RD providing recommendations to increase nutritional supplements and consider an appetite stimulant, a care plan was not developed for the resident. The RD stated that care plans were typically developed by the nursing staff and Dietary Supervisor (DS) based on the RD's notes, but the RD did not personally develop a care plan due to time constraints. The DS confirmed that she did not develop a care plan based on the RD's notes nor did she contact the resident's physician for further recommendations. The Director of Nursing (DON) clarified that while nursing could develop care plans according to the RD's notes, the DS did not have the credentials to perform the roles and responsibilities of an RD. The facility's job description for the RD indicated responsibilities for reviewing and assessing nutritional risk reviews and care plans. However, the RD did not fulfill these responsibilities, leading to a lack of comprehensive care planning for the resident. The Academy of Nutrition and Dietetics' guidelines emphasize the importance of collaboration in developing nutrition intervention goals and monitoring progress, which was not adequately followed in this case.
Failure to Maintain Safe and Comfortable Temperatures
Penalty
Summary
The facility failed to maintain comfortable and safe temperatures for Resident 44, who was readmitted with diagnoses including renal dialysis and essential hypertension. The Minimum Data Set indicated that Resident 44 had intact cognition and the capacity to make decisions. During an observation and interview, Resident 44 reported feeling very cold in his room, especially in the morning, which made him uncomfortable and reluctant to get up for breakfast. The thermostat in Resident 44's room was observed to be set at 70 degrees, which is below the facility's policy range of 71 to 81 degrees for comfortable and safe temperatures. The Maintenance Supervisor (MS) acknowledged that the resident room temperature logs were incomplete, with the last recorded temperature check on December 4, 2024. During a subsequent observation, room temperatures were recorded at 70 degrees, except for one room at 24 degrees. The MS admitted to not remembering the last time the air-conditioning and heating systems were repaired. The Director of Nursing (DON) confirmed that staff could adjust the thermostat settings and acknowledged that excessively cold temperatures could lead to residents becoming sick and uncomfortable. The facility's policy emphasized providing a homelike environment with person-centered care, including maintaining comfortable temperatures, which was not adhered to in this instance.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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