Kit Carson Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, California.
- Location
- 811 Court Street, Jackson, California 95642
- CMS Provider Number
- 056198
- Inspections on file
- 36
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 66
Citation history
Health deficiencies cited at Kit Carson Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with constipation, muscle weakness, and CKD experienced repeated periods without documented BMs, frequent foul‑odor stools, abdominal pain, intermittent diarrhea, and decreasing oral intake. CNAs reported these issues to nurses, but there was no documentation of nursing assessment, bowel regimen initiation, or physician notification despite facility expectations. Over several days the resident’s ADLs declined from independent showering to needing assistance with showers, dressing, and transfers, with abdominal tenderness and low diastolic BP, yet staff treated this as non‑emergent, did not obtain fresh VS, and relied on a written note in a communication binder rather than direct MD contact. Later, when the resident had diarrhea and lay in a fetal position holding her abdomen, the IP obtained an order for PRN Imodium but did not perform a full abdominal or pain assessment, did not update VS, did not communicate the full presentation to the MD, and the first dose was delayed until the next day. Weekly summary assessments were missed for multiple weeks, and RNs did not complete or sign off on change‑of‑condition assessments as required, contributing to inadequate monitoring and escalation of the resident’s worsening condition.
A facility failed to maintain sufficient CNA staffing and timely call-light response when two scheduled CNAs, both from a registry, were unavailable for an evening shift and no replacements were secured. A resident with bowel incontinence and dependence for toileting activated the call light after becoming soiled and reportedly waited about two hours before an unassigned CNA responded, finding the resident crying, soiled, and with red skin. Staffing records showed one CNA called off and another left early without returning or clocking in/out, and there was no documentation of reassigned CNA coverage for the affected rooms. Staff interviews described unanswered call lights and reliance on registry staff, while facility policies required sufficient and competent staffing, call-light response within 3–5 minutes, adherence to protocols by registry staff, and treatment of residents with dignity and respect.
A resident with a history of venous thrombosis and embolism, and intact cognition, had a standing order for Xarelto 20 mg daily at 5:00 PM. On one evening, a registry nurse could not initially locate the medication, and the dose was ultimately given at 6:43 PM, outside the facility’s one-hour before/after administration window. Review of the EMAR, Medication Audit Report, and progress notes showed no documentation explaining the delay, and there was no recorded notification of the physician or pharmacy. This conflicted with facility policies requiring timely administration per MD orders, proper medication storage and access, registry staff competency in medication procedures, and documentation and provider notification when a medication error occurs.
A resident with multiple comorbidities, including HTN, AFib, and CKD, received metoprolol 12.5 mg BID despite repeated low BP readings documented on the MAR. An LN confirmed administering the medication on days with low systolic BP and acknowledged that no specific hold parameters had been obtained from the physician. The DON stated that facility practice was to hold BP meds for HTN when systolic BP was below 110, yet review of the MAR showed metoprolol was given multiple times below this threshold. The resident had no care plan addressing HTN or metoprolol use, including monitoring for adverse effects or its BBW, and the consultant pharmacist’s MRR did not identify or recommend action regarding the missing parameters or low BP readings, preceding a change in condition and hospitalization for very low BP.
A resident with diabetes, dysphagia, and orders for a pureed diet with nectar‑thick liquids and a CCHO plan had a jar of peanut butter and jelly at the bedside and reported eating it directly from the jar because he disliked facility food. Nursing staff and a CNA knew the resident sometimes ate peanut butter and jelly and was non‑compliant with his diet but did not recognize or act on the conflict with his ordered pureed/nectar‑thick, CCHO diet or his aspiration precautions. The CDM and ST were unaware the resident was consuming peanut butter and jelly and had not evaluated its safety or appropriateness, while the resident’s significant other stated she had been bringing it for months after being told she could bring any food. The facility’s policy requiring interdisciplinary review and documentation when resident food preferences conflict with prescribed diets was not followed, resulting in ongoing access to food inconsistent with the physician’s orders.
A resident with a history of hypertension, pulmonary emboli, and prior stroke had a care plan addressing brief loss of consciousness (LOC), including nursing assessment, monitoring V/S and O2 sats, physician notification, and placing the resident supine with legs elevated. On one morning, the resident experienced an LOC episode during PT; rehab staff laid the resident on a mat but did not obtain V/S, did not position the resident per the care plan, did not secure a nurse assessment, and did not notify the MD, then resumed therapy. Later the same morning, the resident had a second LOC episode in the room; a CNA initially could not obtain BP, an LN briefly entered and left without assessing, and although BP was later obtained and an assessment performed, MD notification was delayed by more than 40 minutes. The DON and DOR confirmed that the resident’s care plan and facility policies on change of condition, nursing assessment, and comprehensive care planning were not followed.
The facility failed to follow its infection prevention and control practices when multiple used towels were left piled on the floor of a shared bathroom for two days. Two residents with multiple cardiac, neurologic, vascular, renal, and endocrine diagnoses shared this bathroom; one resident reported using the towels for personal cleaning and leaving them under the sink, not knowing where to place them and expecting staff to remove them, while the other resident expressed concern he might accidentally use the towels. A CNA, an LN, the IP nurse, and the DON all acknowledged that towels should not be on the floor and should instead be bagged and placed in a soiled laundry bin, consistent with the facility’s IPCP policy requiring a safe, sanitary environment and staff adherence to proper infection control techniques.
A resident with a chronic right lower leg venous ulcer, cellulitis, and diabetes experienced a significant wound decline, with the wound MD observing 100% slough/necrotic tissue, heavy drainage, and excruciating pain. The wound MD urgently recommended hospital admission for operative debridement and the MD gave a verbal order for a vascular surgery consult, but nursing staff did not immediately document or act on these orders, and the vascular referral was not entered for several days. Required 72‑hour change‑of‑condition monitoring with per‑shift VS and pain scores was not initiated or completed, and documentation of the wound MD’s assessment was entered days later without being labeled as a late entry. The TAR showed multiple missed Dakin’s solution treatments, and the wound MD reported finding dry, adherent dressings that suggested daily dressing changes were not being done as ordered. The resident was later transferred to the hospital with septic shock and necrotizing fasciitis of the right leg and died from cardiopulmonary arrest, septic shock, and necrotizing fasciitis.
A resident with diabetes, cellulitis, severe cognitive impairment, and a chronic right lower leg venous ulcer experienced documented worsening of the wound from mixed granulation/slough to 100% slough/necrotic tissue with heavy drainage and severe pain. The WD recommended hospital admission for operative debridement and possible leg amputation, and the WN documented this recommendation and the resident’s pain, but the MD did not review the wound documentation, did not personally reassess the wound, and chose not to send the resident to the hospital at that time. Instead, the MD gave a verbal order for a vascular surgery consult that was not entered into the record for five days, during which only two attempts were made to obtain consent from the responsible party. The resident later showed signs of acute decline, including hypotension, tachypnea, altered responsiveness, and refusal of medications and food, and was ultimately hospitalized with septic shock related to right lower extremity cellulitis and later died; this sequence of events formed the basis of the deficiency for failure of effective physician oversight and timely medical intervention.
A resident with osteoarthritis and dementia experienced an unwitnessed fall and developed persistent moderate to severe L hip pain and marked declines in mobility and weight-bearing ability. Nursing initially notified the MD only of the fall and pain, resulting in a PRN Norco order and a routine x-ray order. Over the following days, PT and OT documented 9–10/10 pain with movement, inability to ambulate or bear weight on the LLE, and increasing assistance needs for bed mobility, transfers, and ADLs, while CNAs reported that the resident could no longer roll in bed, required two-person assist, and cried out in pain during care. The MAR showed frequent Norco use for elevated pain scores, but progress notes contained no evidence that these ongoing changes were reported to the MD. The MD stated he was not informed of the resident’s inability to bear weight, transfer, or walk and ordered the x-ray as routine based on limited information. An eventual x-ray at the hospital revealed a new L hip fracture, and the DON confirmed that the facility failed to report the resident’s prolonged pain and mobility decline to the physician as required by policy.
A resident with Type 2 DM, osteomyelitis, and a chronic left foot ulcer had a physician order for fasting blood sugar checks before breakfast with instructions to notify the physician for BG results above 200 mg/dl and a documented goal for improved BG control. Over a multi-day period, ordered FSBS checks before breakfast were not completed on most days, and one elevated BG value of 256 mg/dl was documented without physician notification or treatment. Interviews with an LN and the DON confirmed the missed FSBS checks, the lack of interventions for the elevated BG result, and the absence of care plan interventions to achieve the stated BG control goal, contrary to facility policies and clinical protocols for glucose monitoring and acute condition changes.
A resident who had recently sustained a fall resulting in a left hip and femur fracture, along with conditions such as muscle weakness, kidney disease, and osteoporosis, was re-admitted to the facility without a fall awareness or fall prevention care plan in place. Despite facility policy requiring evaluation, management, and documentation of interventions for residents at risk for falls, and staff acknowledgment that a fall care plan is part of post-fall protocol and necessary to guide care, the resident’s clinical record contained no fall care plan, leaving staff without documented guidance for fall prevention.
Two residents' rights to privacy were violated when CNAs took unauthorized photographs of them and their rooms using personal phones, without obtaining consent from the residents or their responsible parties. One resident, who had a colostomy bag, was photographed in a compromised state, and another resident was photographed despite being unable to provide consent. These actions were in direct violation of facility policy regarding resident privacy and dignity.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs.
The facility did not ensure that the most recent federal survey results were accessible to residents, family members, or legal representatives. Residents were unaware of where to find the survey results, and staff, including the IP and ADM, could not locate the survey results binder, which was supposed to be by the front door but was missing during inspection. The DON confirmed that without the binder, residents could not review the survey findings or know what the facility was addressing.
The facility did not maintain a working call light system, resulting in residents' requests for assistance not being promptly communicated to staff. Staff and administration confirmed the system had not provided audible or visual alerts at the nurses' station for over a year, leading to multiple instances where call lights were left unanswered for extended periods. Facility policy required timely response to call lights, but observations showed this was not met due to the system's failure.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not provide or document required education on the benefits and potential side effects of the COVID-19 vaccine for three residents prior to vaccine administration, as confirmed by the Infection Preventionist and review of immunization records. This omission was not in accordance with facility policy, which requires education and documentation before vaccination.
A resident was administered psychotropic medications without clear medical necessity or was given medications that restrained their ability to function, resulting in a deficiency related to medication management.
Two residents were placed at risk when one was left smoking unsupervised without an updated smoking assessment, and another was on oxygen therapy without required 'oxygen in use' signage posted at the room entrance. Staff failed to follow facility policies regarding supervision and safety assessments.
A resident with a history of hypertensive heart disease and heart failure was given Midodrine on seven occasions despite physician-ordered parameters to hold the medication if systolic blood pressure was above 120 mmHg. Nursing staff confirmed the medication was administered in error and that required documentation and notifications were not completed, as per facility policy.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Menus were not consistently prepared in advance, followed, updated, or reviewed by a dietician, resulting in residents' nutritional needs not being met as required.
Two residents did not receive meals in accordance with their documented dietary requirements and preferences during a lunch service, with one not receiving the specified milk and another being served a disliked food item, despite facility policies and staff expectations to honor such preferences.
Two residents with significant nutritional and physical needs were not provided with the specialized eating utensils indicated on their meal tickets during a lunch meal. Despite documentation and physician orders for adaptive devices, kitchen staff delivered regular utensils, and staff interviews confirmed the omission was not in line with facility policy or care plans.
Two residents identified as at risk for dehydration did not have fluids available at their bedside, contrary to facility policy and their care plans. Staff confirmed the lack of fluids and observed signs of dehydration, including dry mucous membranes, chapped lips, dry skin, and concentrated urine. The DON stated that fluids should always be available and within reach, and that CNAs are responsible for providing fresh fluids each shift and with meals.
Two residents did not receive proper pharmaceutical services when one did not receive a physician-ordered PRN inhaler due to pharmacy unavailability, and another received an IV antibiotic from the E-kit without required documentation of its removal. Staff interviews and record reviews confirmed that established procedures for medication follow-up, communication, and emergency kit documentation were not followed, resulting in medication unavailability and incomplete records.
A resident with chronic heart failure was receiving oxygen therapy, but staff failed to develop a care plan for this intervention. Both nursing staff and the DON confirmed that no care plan was created, despite facility policy requiring comprehensive, measurable care plans for all residents. This omission resulted in a lack of documented goals and interventions for the resident's oxygen use.
Two residents prescribed antipsychotic medications did not have their required quarterly AIMS assessments completed, as confirmed by record review and staff interviews. Both residents had complex psychiatric and cognitive diagnoses and had been receiving antipsychotic therapy for several months, but their AIMS assessments were left blank and no other completed assessments were found, contrary to facility policy.
A resident with cerebral infarction and vascular dementia had conflicting end-of-life treatment preferences documented, with both DNR and Full Treatment marked on the POLST form and in the electronic medical record. Nursing staff and the DON confirmed the inconsistency, and the resident's representative clarified that no resuscitation or life-prolonging measures were desired. The facility's process for reviewing POLST forms failed to identify and correct the error.
A resident was subjected to physical restraints that were not required for medical treatment, in violation of regulations that mandate residents remain free from unnecessary restraints.
A resident with a urinary catheter was found with their catheter drainage bag exposed and not covered by a dignity bag, contrary to facility policy and staff expectations. Staff interviews confirmed that the privacy cover should have been in place to protect the resident's dignity and privacy.
A resident received the pneumococcal vaccine without documented education on its benefits and potential side effects. The Infection Preventionist confirmed that education should be provided and documented prior to vaccination, but the resident's record lacked this evidence, resulting in a violation of the resident's right to make an informed choice.
Two residents with dementia and a history of wandering were not consistently monitored as required, with missed documentation of Wander Guard device checks and overdue elopement risk assessments. One resident exited the facility unsupervised and was found outside, with no follow-up documentation or reassessment completed. Weekly checks of the Wander Guard system were also not documented, despite being performed.
A resident with osteoporosis and muscle weakness was transferred from a shower chair to bed by a CNA using a one-person 'bear-hug' technique instead of the required two-person assist with a gait belt, resulting in a fractured rib. The resident's care plan and MDS indicated the need for substantial assistance, but the transfer was performed alone and without proper equipment, contrary to facility policy and staff training. Staff interviews revealed a lack of clear documentation and confusion about transfer requirements, contributing to the incident.
A resident with multiple sclerosis was physically abused by another resident with severe mental illness and violent behavior. The attacking resident entered the victim's room and struck him multiple times, causing injuries. Despite a history of violence, the facility failed to provide adequate supervision, leading to the incident. Staff and other residents expressed fear, and the facility's administrator did not classify the attack as abuse, contrary to policy.
The facility failed to ensure full-time onsite supervision by a Dietary Supervisor (DS) and adequate oversight by a Registered Dietitian (RD) for food and nutrition services. The DS worked only three days a week, leaving the kitchen unsupervised on other days, while the RD's limited presence focused on clinical duties, resulting in potential lapses in meal distribution and sanitation for 81 residents.
The facility failed to meet food safety standards, with wet-stored utensils, expired and mislabeled food, and unclean equipment. Observations included spoiled produce, improperly thawed meat, and unmonitored resident refrigerators. Staff lacked knowledge in food cooling and dishwashing processes, highlighting significant training needs.
The facility failed to maintain a clean environment by not securing one of the garbage disposal bins near the kitchen, leaving trash exposed. The Dietary Supervisor and Registered Dietitian acknowledged the importance of keeping lids tightly closed to prevent pest infestations. Facility policy and the FDA Food Code require sealed, tightly closed containers for food waste to avoid nuisances.
The facility failed to ensure proper training for food service personnel, leading to deficiencies in manual dishwashing and meat thawing procedures. A dietary aide was unable to correctly verbalize the dishwashing process, lacking knowledge of water temperatures and sanitizing steps. Another staff member improperly thawed meat using hot water instead of the required running cool water. Both staff members had not received adequate training, and one had an expired food handler permit.
The facility did not follow prescribed dietary requirements during a lunch meal service, affecting several residents. Sixteen residents on a CCHO diet received diet gelatin without whipped topping, and twelve residents on low fat/low cholesterol and 2 grams sodium diets were served salad with regular dressing. Six residents on a pureed diet did not receive pureed salad. A resident requiring a double meat portion received only a single portion, and another resident on a fortified diet did not receive extra gravy. These failures were identified through observation, interviews, and record reviews.
The facility failed to ensure safe pharmaceutical services, including undocumented destruction of non-controlled medications, mismanagement of emergency kits, and inconsistent signing of drug delivery manifests. Additionally, there was a discrepancy in the documentation of narcotic medication for a resident, with the Controlled Drug Record not matching the Medication Administration Record.
A facility failed to monitor vital signs according to physician orders for residents on high-risk medications. One resident received blood pressure medications despite low systolic readings, another was transferred to the ER after receiving heart medications with low blood pressure, and a third received heart medications despite low pulse readings. Staff interviews revealed non-compliance with the facility's medication administration policy.
The facility failed to ensure safe use and monitoring of psychotropic medications for three residents. Non-pharmacological interventions were not documented, and PRN medication use continued beyond 14 days without proper assessment. Interdisciplinary team meetings did not address mental health issues effectively, leading to deficiencies in care.
The facility failed to conduct interdisciplinary care conferences for several residents, as required by policy. Residents reported not attending these meetings, and record reviews showed incomplete documentation. The Social Services Director admitted to not scheduling these conferences, and other staff confirmed they did not participate in coordinated care planning. The facility's policy mandates these meetings to ensure comprehensive care, but this was not followed.
A facility failed to ensure accurate documentation of end-of-life wishes for six residents, leading to discrepancies between POLST forms and physician orders, and missing Advance Directives in medical records. This resulted in confusion among staff about residents' treatment preferences during emergencies.
The facility failed to maintain professional standards by not consistently completing glucometer QC tests and leaving a resident's medication unattended. The glucometer logbook lacked necessary entries, and a resident's medication was left on their bedside table, contrary to facility policy. These actions risked inaccurate glucose tests and medication errors.
The facility failed to ensure safe storage and handling of medications and supplies, with issues including a frosted refrigerator, expired glucometer solutions, unlocked emergency kits, and improper handling of hazardous drugs. Staff were unaware of safety protocols, leading to potential risks for residents.
A facility failed to follow infection prevention practices by not cleaning a glucometer between resident uses and using expired hand sanitizers. An LPN did not disinfect the glucometer between two residents' blood glucose tests, and nine expired hand sanitizer bottles were found in use. The Infection Preventionist and DON confirmed these practices did not meet guidelines.
Failure to Assess, Monitor, and Notify Physician for Resident With Constipation, Abdominal Pain, and ADL Decline
Penalty
Summary
The deficiency involves the facility’s failure to provide assessment, monitoring, and physician notification consistent with professional standards for a resident with constipation, abdominal pain, and progressive decline. The resident had multiple diagnoses including constipation, muscle weakness, and chronic kidney disease. Bowel movement (BM) records showed repeated periods with no documented BM for 2–6 days over December and January, as well as frequent documentation of foul‑odor stools. CNAs reported that the resident frequently complained of abdominal pain, pointed to her mid‑abdomen, had foul‑smelling stools, and experienced intermittent diarrhea, nausea, and decreased oral intake, and that these concerns were reported to nurses. The DON confirmed that there was no documentation that nurses assessed the resident, notified the physician, or implemented a bowel regimen when the resident went multiple days without a BM or when foul‑odor BMs were recorded, despite facility expectations and standing bowel regimen orders. The resident also experienced a progressive decline in ADLs and mobility that was not appropriately escalated. On one date, an SBAR documented that the resident reported feeling too weak to shower independently, had lower back and abdominal pain, decreased mobility, and abdominal tenderness, with a blood pressure of 116/48. Nursing progress notes over the next two days documented that the resident went from needing help with showers only to needing assistance with dressing and then transfers, indicating increasing weakness. The nurse categorized this as a non‑emergent change, placed a written note in a communication binder instead of directly calling the physician, and did not obtain a fresh set of vital signs at the time of the change in condition. The physician’s late‑entry progress note for a visit the next day did not address the ADL decline or abdominal tenderness, and there was no documentation that the physician had been directly informed of these changes. The DON stated that such ADL decline and abdominal tenderness should have been reported to the physician right away and that the SBAR did not reflect the full extent of the resident’s progressive decline. On another date, the Infection Preventionist completed an SBAR for the resident’s diarrhea but did not perform a comprehensive assessment or fully communicate the resident’s condition. The SBAR documented that the resident had diarrhea twice a day and was lying in a fetal position holding her stomach, but the IP reported that he only informed the physician about the diarrhea and request for medication, not the fetal position or abdominal holding. He did not obtain new vital signs, did not palpate the abdomen, did not auscultate bowel sounds, and did not assess pain, and he entered earlier vital signs into the SBAR instead. The IP obtained an order for PRN Imodium but did not administer the first dose, stating he believed he endorsed it to the oncoming nurse; the medication was first given the next morning. Meal intake records showed the resident repeatedly refused or minimally consumed meals over several days, but there was no nursing documentation of assessment related to decreased intake. The DON stated that repeated meal refusals or decreased intake over multiple days should be reported to the nurse and then to the physician. Additionally, required weekly summary assessments and RN involvement in change‑of‑condition assessments were not completed as expected. The DON verified that weekly summary assessments were missing for multiple weeks in December and January and all of February, even though they were expected every Wednesday. These weekly summaries were described as comprehensive assessments of weight, skin, mental status, bowels, eating, ADLs, medications, and fluids, and as a means of monitoring for changes that would trigger a change‑of‑condition evaluation and physician notification. The DON also confirmed that SBARs for the resident’s changes in condition on two key dates were completed by an LVN, with no documentation that an RN assessed the resident or signed off, despite the facility’s stated practice that an RN should assess residents after a change in condition. Hospital records later documented that the resident presented with several weeks of abdominal pain, diarrhea, and increasing weakness, was found to have colitis with possible microperforation and significant constipation, and ultimately had a perforated sigmoid colon with fecal contamination, septic complications, and death.
Failure to Maintain Sufficient CNA Staffing and Timely Call-Light Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff were available on a specific evening shift, resulting in unmet care needs for a resident who was fully dependent on staff for toileting and hygiene. On that evening, two CNAs who were scheduled to work were unavailable: one CNA called off for the shift, and another CNA, a registry staff member, left early and did not return. No replacement staff were secured for either CNA, and the facility was unable to produce accurate documentation of how CNA assignments were regrouped or redistributed after these staffing losses. As a result, there was no documented reassignment for the resident care groups that included the affected resident’s room. The resident involved had diagnoses including constipation and Ogilvie syndrome and was documented as always incontinent of bowel and dependent for toileting and hygiene per the MDS Section GG and Section H. The resident was cognitively intact, with a BIMS score of 14, and resided on Station 1. On the evening in question, the resident reported becoming soiled due to her medical condition and activating the call light for assistance. She stated that the registry CNA assigned to her care left early and did not return, and that she waited approximately two hours after activating the call light before receiving help. During an interview and observation, the resident became teary while recounting the event and explained that managing her uncontrollable bowel movements was difficult. Multiple staff interviews and record reviews corroborated the staffing and response issues. Review of the NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET confirmed that one registry CNA called in and another registry CNA signed in for the shift but left early and did not clock in or out, with no replacement staff identified. The DSD, IP, and Human Resources/Maintenance Director confirmed there was no documentation of revised CNA assignments for the affected resident groups after the staffing changes. Staff, including a CNA who was not assigned to the resident, reported that call lights were not consistently answered that evening and that multiple call lights were observed unanswered. This CNA responded to the resident’s call light, found the resident crying and in a soiled brief, and observed that the resident’s skin appeared red when she was changed. Facility policies reviewed indicated that staffing should be sufficient and competent to meet resident needs, call lights should be answered within 3–5 minutes, registry staff should follow facility protocols and documentation requirements, and residents should be treated with respect, kindness, and dignity.
Late Administration of Anticoagulant by Registry Nurse Without Documentation
Penalty
Summary
The deficiency involved the facility’s failure to ensure a prescribed anticoagulant was administered within the facility’s established time frame and in accordance with professional standards of practice. A resident with a history of venous thrombosis and embolism, and with intact cognition as evidenced by a BIMS score of 14/15, was ordered Xarelto 20 mg daily at 5:00 PM. On the evening in question, the resident reported that a registry nurse assigned to her was unable to find her Xarelto, and that it took some time before the medication was administered. Review of the EMAR and Medication Audit Report showed that the Xarelto dose scheduled for 5:00 PM was actually administered at 6:43 PM, which exceeded the facility’s acceptable administration window of one hour before or after the scheduled time. Record review from 2/19/26 to 2/24/26 revealed no documentation explaining the reason for the delayed administration of Xarelto on that date. During interviews, the DON and Infection Preventionist confirmed that the administration time was 43 minutes beyond the acceptable window and acknowledged there was no documentation of the cause of the delay. Both indicated it was likely the registry nurse did not know where to locate the medication. Facility policies required medications to be administered in accordance with physician orders and within one hour before or after the scheduled time, required registry staff to be oriented and competent in facility-specific medication administration procedures, and defined medication errors to include omissions of vital medications, with prompt physician notification and documentation of the error and subsequent orders. Policies also required medications to be stored safely, securely, and properly, with access limited to authorized staff. These requirements were not met in this incident, as the anticoagulant was administered late, the reason for the delay was not documented, and there was no documented notification of the physician or pharmacy.
Failure to Safely Monitor and Administer Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and safe administration of metoprolol for a resident treated for hypertension. The resident was admitted with multiple diagnoses including diabetes mellitus, anemia, atrial fibrillation, acute respiratory failure with hypoxia, and chronic kidney disease. Progress notes documented that on one day the resident had a blood pressure of 100/58, appeared deeply asleep, refused medications and food at lunchtime, and then went back to sleep. The following day, progress notes documented a blood pressure of 86/58, lethargy, slow response, pallor, and that the resident was not responding per baseline, leading to physician contact and transfer to the emergency room. Review of the Medication Administration Record (MAR) showed that the resident had a physician order for metoprolol tartrate 12.5 mg by mouth twice daily for hypertension. The MAR documented multiple low blood pressure readings in January and February, including systolic readings at or near 100 mmHg, on days when metoprolol was administered. A licensed nurse confirmed that she administered metoprolol on days when low blood pressure readings were recorded and acknowledged that when blood pressure medication orders do not include parameters, the nurse should assess the resident, review blood pressure readings, notify the physician, and request clarification for safe parameters. She further stated that if metoprolol had included parameters for holding the medication, the recent change in the resident’s condition that resulted in hospitalization due to very low blood pressure might have been avoided. The DON stated that the facility’s process for administering blood pressure medications included holding parameters based on diagnosis: for residents treated for hypertension, nurses should hold blood pressure medication if systolic blood pressure is less than 110, and for residents treated for heart failure, if systolic blood pressure is less than 100. The DON’s review of the MAR confirmed that metoprolol was administered multiple times when the resident’s systolic blood pressure was below 110, which was not consistent with the facility’s stated process. The DON also confirmed that the resident did not have a care plan addressing hypertension or the use of metoprolol, including monitoring for potential adverse effects and its black box warning. Additionally, the February Medication Regimen Review completed by the consultant pharmacist included the resident but did not contain any recommendations regarding the lack of medication parameters or the documented low blood pressure readings.
Failure to Control Off‑Diet Peanut Butter and Jelly for Resident on Pureed, Nectar‑Thick, CCHO Diet
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food available to a resident was consistent with the physician‑ordered pureed diet with mildly thick (nectar‑thick) liquids and a consistent carbohydrate (CCHO) plan. The resident had multiple diagnoses, including diabetes mellitus, anemia, atrial fibrillation, acute respiratory failure with hypoxia, and chronic kidney disease, and was on aspiration precautions with safe swallowing instructions posted at the bedside. Despite these orders and precautions, surveyors observed a jar of Smucker’s Goober Strawberry Peanut Butter & Jelly Stripes on the resident’s bedside table within reach. The resident reported that he did not like the pureed food served by the facility, acknowledged having difficulty swallowing, and stated that he had been eating peanut butter and jelly directly from the jar since the previous year without being told it could be unsafe. Nursing and CNA staff were aware that the resident was sometimes non‑compliant with the prescribed diet and had seen him eating peanut butter and jelly, but they did not recognize or act on the potential conflict with his ordered pureed/nectar‑thick, CCHO diet. The LN confirmed the resident’s diet order and aspiration precautions, acknowledged seeing him eat peanut butter and jelly, and admitted uncertainty about whether it was safe. The CNA stated that the resident did not like the pureed food, had observed him eating peanut butter and jelly as a snack, and knew he was sometimes non‑compliant with his diet, but was not aware of his swallowing precautions and did not know that peanut butter and jelly could be unsafe for him. Neither staff member reported the issue through the facility’s processes or sought further assessment of the resident’s swallowing in relation to this food. The dietary and therapy departments were also not informed of the resident’s ongoing consumption of peanut butter and jelly. The Certified Dietary Manager, upon review of the electronic health record, confirmed the resident’s CCHO diabetic dysphagia diet with pureed texture and nectar‑thick liquids and stated that peanut butter and jelly did not meet the physician‑ordered diet due to both texture and sugar content. The Speech Therapist reported that she had not evaluated the resident for some time, was unaware that he was eating peanut butter and jelly directly from the jar, and had never assessed his ability to safely swallow that food. The resident’s significant other stated that she had been bringing peanut butter and jelly for about three months, that staff had told her she could bring any food she wanted, and that she continued to bring it because the resident would not eat otherwise, despite being aware there could be safety concerns. The facility’s policy on resident food preferences required the dietitian and nursing staff, with physician involvement, to address conflicts between resident preferences and prescribed diets, but this process was not implemented in relation to the resident’s peanut butter and jelly consumption. Overall, the facility did not ensure that the resident’s available food was consistent with the ordered pureed, nectar‑thick, CCHO diet, did not communicate or coordinate among nursing, dietary, and therapy staff regarding the resident’s off‑diet food brought by family, and did not follow its own policy for managing resident food preferences that conflict with prescribed diets. This resulted in the resident having independent access to and consuming peanut butter and jelly that did not conform to his physician‑ordered diet and swallowing precautions.
Failure to Implement Care Plan After Episodes of Loss of Consciousness
Penalty
Summary
The deficiency involves the facility’s failure to implement an existing care plan for a resident who experienced episodes of brief loss of consciousness (LOC). The resident had multiple significant diagnoses, including hypertension, multiple segmental thrombotic pulmonary emboli, cerebral infarction with aphasia, muscle weakness, and facial weakness. The resident’s care plan, initiated several days prior, identified a focus on episodes of brief LOC and included interventions such as assessing the resident, monitoring for further syncopal episodes, monitoring vital signs (V/S) and O2 saturations, notifying the physician for any change of condition, and placing the resident in a supine position with legs elevated. On the morning in question, the resident experienced a first LOC episode in the rehabilitation room while standing at parallel bars during PT. The PTA reported that the LOC lasted about 30 seconds, during which the resident was laid on a fall mat. Another rehab staff member left to look for a nurse but returned stating that no nurse could be found, and no licensed nurse came to evaluate the resident. Despite a BP machine being available in the rehab room, the resident’s V/S were not taken, O2 sats were not monitored, the resident was not placed supine with legs elevated per the care plan, and the physician was not notified. After the resident regained consciousness, the PTA continued the mat program without a nursing assessment or implementation of the care plan interventions. Later that morning, the resident had a second LOC episode while in a wheelchair in his room, witnessed by a family member and a PTA. After the resident briefly lost consciousness and then attempted to vomit, CNA 1 attempted to obtain BP with a wrist monitor but initially could not get a reading and left to call for a licensed nurse. When LN 1 first entered the room, he stated he had just returned from lunch and left without assessing the resident. CNA 1 then obtained a BP reading several minutes later, and LN 1 returned and assessed the resident, who appeared pale, cold to touch, and sweaty. The family member reported this was the second LOC episode that morning and that no nurse had come after the first episode. LN 1 stated he did not receive notification of the first LOC and acknowledged that physician notification after the second episode was delayed by more than 40 minutes. The DON confirmed that the resident’s care plan interventions for LOC, including nursing assessment, monitoring V/S and O2 sats, physician notification, and placing the resident supine with legs elevated, were not implemented during the first episode and were not timely during the second episode, contrary to facility policies on nursing assessment, change of condition, and comprehensive care plans.
Soiled Towels Left on Shared Bathroom Floor Breach Infection Control Practices
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices when multiple used towels were left on the floor of a shared bathroom used by two residents for two days. One resident, who had diagnoses including nonrheumatic aortic valve stenosis, chronic atrial fibrillation, atherosclerotic heart disease, hypertensive urgency, chronic kidney disease stage II, and dementia, shared the bathroom with another resident diagnosed with cerebral infarction, chronic atrial fibrillation, peripheral vascular disease, hypothyroidism, sick sinus syndrome, and alcohol use. During observation, the shared bathroom door was open, and multiple used towels were piled on the floor under the sink in clear view of one resident lying in bed. That resident reported using the towels for cleaning herself, stated she did not know where to place the used towels, and confirmed they had remained under the sink for two days, expecting staff to pick them up. The other resident stated he did not like used towels on the floor because he might accidentally use them. CNA staff stated they were expected to ensure residents’ rooms were clean and that towels should not be left on the floor, acknowledging that soiled towels on the floor created an infection control concern, especially if another resident used them. A licensed nurse confirmed the presence of the pile of towels on the bathroom floor and stated that soiled towels should be placed in a plastic bag, closed, and then placed in a laundry bin outside the room to prevent contamination and spread of infection. The Infection Prevention Nurse and the Director of Nursing both stated that used towels should not be placed on the floor and should instead be bagged and placed in a soiled bin because they may contain hazardous material and could harbor germs and microorganisms. The facility’s Infection Prevention and Control Program policy indicated that an IPCP is to be established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including educating staff and ensuring adherence to proper techniques and procedures.
Failure to Implement Wound MD and MD Orders, Monitor Change of Condition, and Provide Ordered Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services and to follow professional standards in managing a resident’s worsening right lower leg venous ulcer and associated change in condition. The resident had a history of a non‑pressure chronic ulcer of the right lower leg, cellulitis, and type 2 diabetes, with severe cognitive impairment and a responsible party designated for decision‑making. Weekly skin assessments initially documented the wound as improving, but a later assessment described the wound as worse, with 100% slough/necrotic tissue and heavy drainage. During wound rounds on that date, the wound doctor (WD) observed the deterioration, noted the resident was in excruciating pain despite pre‑medication, and verbally recommended hospital admission for operative debridement above and below a possible leg amputation. The WD communicated this recommendation to the medical director (MD) and the wound nurse (WN), and the MD agreed that the resident needed a higher level of care and a vascular surgery evaluation. Despite this, the facility did not timely implement the WD’s recommendation or the MD’s verbal order. The MD stated he gave a verbal order on the same date for the resident to be seen by a vascular surgeon and expected it to be carried out within 24 hours. However, the vascular surgery referral order was not entered into the medical record until five days later, and the consultation was not arranged before the resident was ultimately transferred to the hospital. The DON confirmed that the WN did not follow the facility’s policy requiring verbal orders to be recorded immediately and acknowledged that the order for vascular consultation was delayed. The WN also documented the WD’s assessment and recommendation as a progress note several days after the event without labeling it as a late entry, and the DON stated this late, unlabeled documentation could cause confusion and was not acceptable practice. The responsible party reported never refusing hospital transfer or raising cost concerns, and described the resident’s rapid cognitive decline and severe leg pain during this period. The facility also failed to initiate and complete required monitoring and wound treatments after the change in condition was identified. The WN and DON both stated that the resident’s worsening wound and severe pain on the date of the WD’s assessment constituted a change of condition that should have triggered 72‑hour monitoring with vital signs and pain assessments every shift. Review of progress notes and the SBAR form showed that this monitoring was not initiated on the date of the change and was not completed every shift for 72 hours. The DON confirmed that vital signs and pain scores were not documented each shift following the change in condition. In addition, the Treatment Administration Record showed multiple missed Dakin’s solution treatments to the right lower leg venous ulcer on several days, and the WD reported that, on weekly visits, the dressings were dry, hard to remove, and stuck to the wound, leading him to question whether daily dressing changes were being performed as ordered. The DON verified the missed treatments and stated this created a risk of wound deterioration. Ultimately, the resident was sent to the hospital with confusion, hypotension, tachypnea, and laboratory evidence of sepsis, was diagnosed with septic shock related to right lower extremity cellulitis and necrotizing fasciitis, and died from cardiopulmonary arrest, septic shock, and necrotizing fasciitis of the right leg.
Failure of Physician Oversight and Timely Response to Worsening Venous Leg Ulcer
Penalty
Summary
The deficiency involves the failure of the Medical Director/attending physician to effectively oversee, supervise, and assess a resident’s medical care in relation to a worsening right lower leg venous stasis ulcer. The resident was admitted with diagnoses including a non‑pressure chronic ulcer of the right lower leg, cellulitis, and type 2 diabetes, and had severe cognitive impairment with a responsible party designated for decision‑making. An order was in place for wound evaluation and treatment by an outside wound care company, and weekly skin assessments documented the wound’s status. On one weekly assessment, the wound nurse documented that the right lower leg venous ulcer measured approximately 15 cm x 5 cm x 0.4 cm post‑debridement, with 50% slough and 50% granulation tissue, significant drainage, no odor, no signs or symptoms of infection, and that the wound was showing improvement. On a subsequent weekly assessment, the wound nurse documented that the same wound was worse, with the same measurements but now 100% slough/necrotic tissue and heavy drainage, though still noted as having no odor and no signs or symptoms of infection. During wound rounds on that later date, the wound doctor evaluated the resident’s right lower leg ulcer, determined that bedside wound care was not effective, and recommended hospital admission for operative debridement and possible above‑ and below‑knee amputation. The wound nurse later entered a progress note reflecting that the wound was worsening, had 100% slough/necrotic tissue, heavy drainage, and that the resident was in excruciating pain despite pre‑medication; this note was entered with a later date but described the earlier wound‑rounds encounter, and the nurse acknowledged she did not label it as a late entry to avoid it being flagged. The care plan for skin integrity was updated to include the wound doctor’s recommendation for hospital admission for operative debridement and possible leg amputation. The Medical Director stated that the wound doctor informed him of serious concern about the resident’s non‑healing venous ulcer, significant vascular compromise, and the need for hospitalization and evaluation by a vascular surgeon. The Medical Director reported that he gave a verbal order to the wound nurse for a vascular surgery consult and expected it to be carried out by the following day, but he did not send the resident to the hospital at that time because he did not feel it was urgent and had not reviewed the wound doctor’s notes or the documented deterioration of the wound. The order for the vascular consult was not entered into the medical record until five days after the verbal order, and the DON confirmed that only two attempts were made to obtain consent from the responsible party for the vascular consult during that period. The Medical Director also acknowledged that he did not assess the resident’s right leg ulcer after the wound doctor’s recommendation and could not recall the last time he personally assessed the wound, stating he had not gone out of his way to observe it because the facility had a wound team. Subsequently, the resident experienced a change in condition, with documentation by the wound nurse of low blood pressure (79/42), elevated respirations (30), slightly elevated temperature (99.6°F), non‑responsiveness compared to baseline, refusal of medications, refusal of breakfast, no fluid intake, facial grimacing with moaning, and refusal of pain medication. The resident was later sent to the hospital, where records showed presentation to the ED with confusion, increased heart rate, and low blood pressure due to septic shock related to cellulitis of the right lower extremity. Hospital findings included markedly elevated WBC, elevated lactic acid, CT evidence of a large soft tissue defect with fluid collection extending to the lateral ankle and forefoot muscles, and positive blood cultures for multiple bacteria. The resident was admitted to the ICU, later placed on comfort measures only, and died with causes listed as cardio‑pulmonary arrest, septic shock, and necrotizing fasciitis. Facility documents describing the Medical Director’s duties included coordinating medical care, participating in patient care review and infection control, being responsible for reviewing and evaluating patient care services, and making skin and high‑risk patient rounds, which contrasted with the Medical Director’s statements that he had not reviewed the wound documentation or assessed the wound after the wound doctor’s urgent recommendation.
Failure to Notify Physician of Resident’s Significant Change in Condition After Fall
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident following an unwitnessed fall, resulting in a left hip fracture going undiagnosed for six days. The resident had a history of bilateral primary osteoarthritis of the left hip and vascular dementia and had been functioning with improving mobility in PT and OT prior to the fall. On the morning of the fall, nursing documentation showed the resident was found on the floor lying on the left side, reported left hip pain at 5/10 with sharp, painful-to-touch discomfort, and had some decreased ability to move the left leg. The nurse notified the physician of the fall and pain, and the physician ordered PRN Norco for moderate to severe pain. The physician later, on a follow-up visit, ordered a routine x-ray of both hips and pelvis and therapy reassessment, with the x-ray appointment scheduled for a later date. In the days following the fall, multiple clinical records documented a marked and ongoing decline in the resident’s mobility and persistent moderate to severe pain with movement, but there was no documentation that these changes were communicated to the physician. PT notes from 2/2 through 2/5 recorded that the resident complained of 10/10 pain with movement of the left lower extremity, was unable to ambulate, could not bear weight on the left leg, and required increasing assistance for bed mobility and positioning, with pain at rest remaining low but pain with movement consistently at 9–10/10. OT notes over the same period documented that the resident repeatedly reported 10/10 pain, refused or was unable to participate in weight-bearing activities, and that left lower extremity pain significantly impacted the ability to perform transfers, toileting, and ADLs, limiting therapy to in-chair ADLs and upper extremity strengthening. Therapy staff confirmed that prior to the fall the resident could fully straighten the left leg, had full ROM, and ambulated 50–60 feet with a FWW and contact guard, but after the fall could not walk, bear weight, extend or move the left leg, or roll in bed without severe pain, and that this information was not documented as being communicated to licensed nurses or the physician. Nursing and CNA interviews further described unreported changes in the resident’s condition. CNAs stated that after the fall the resident was in “quite a bit of pain,” could no longer roll in bed as before, required two CNAs for bed mobility instead of one, could not fully extend the left leg, and cried out in pain and said “please, no” during incontinent care and repositioning; these changes were reported to a licensed nurse. The MAR showed a significant increase in the use of Norco for pain scores ranging from 5/10 to 8/10 after the fall. Progress notes from 1/31 through 2/6 contained no evidence that the physician was notified of the resident’s ongoing severe pain with movement, inability to move in bed, stand to transfer, bear weight, or ambulate. The nurse later acknowledged suspecting a possible dislocation or fracture based on the resident’s increased pain and inability to straighten the leg, and confirmed that therapy and CNAs had reported moderate to severe pain and decreased mobility, but he did not report these ongoing issues to the physician because the PRN Norco was effective in reducing pain and an x-ray was already scheduled. The physician stated he was not informed of the resident’s inability to bear weight, transfer, roll in bed, or walk after the initial report and that he ordered the x-ray as routine based on the limited information provided. The DON confirmed there was no documentation that the resident’s mobility declines and prolonged moderate to severe pain were communicated to the physician, despite facility policies requiring assessment and reporting of signs such as pain, decreased mobility, and other acute condition changes for physician evaluation and management. On 2/6, when the x-ray was finally completed at the acute care hospital, it showed a new left hip fracture. The PT and OT discharge summaries documented a clear decline from baseline and from the functional status on 2/1 to the time of transfer, including progression from minimal or contact guard assistance to maximum assistance for bed mobility, transfers, and functional mobility during ADLs, and the inability to ambulate due to safety concerns. The DON stated that these signs and symptoms—pain, decreased mobility, and functional decline—should have been considered a change of condition and reported to the physician, and confirmed that the lack of such reporting delayed the diagnosis and treatment of the resident’s left hip fracture and caused the resident to experience continued declines in mobility and unneeded pain and suffering.
Failure to Monitor and Respond to Ordered Fasting Blood Glucose Checks
Penalty
Summary
The deficiency involves the facility’s failure to provide care and treatment in accordance with professional standards of practice for a resident with Type 2 diabetes mellitus, osteomyelitis, a non-pressure chronic ulcer of the left heel and midfoot, and cellulitis of the left lower limb. The resident was admitted with these diagnoses, and on 12/24/25 the physician ordered fasting blood sugar (FSBS) checks before breakfast with instructions to notify the physician for blood glucose (BG) results greater than 200 mg/dl. A physician progress note dated 12/30/25 directed that blood glucose levels be monitored closely to support wound healing. The resident’s care plan, dated 12/31/25, included a focus on nausea and vomiting with a goal for better control of blood glucose in 14 days, but there were no interventions documented to address how this goal would be met. Review of the Medication Administration Records (MARs) for 12/1/25 through 12/31/25 and 1/1/26 through 1/31/26 showed that FSBS tests before breakfast were not completed on multiple days after the order was initiated. Specifically, there were no FSBS tests documented before breakfast on 12/24/25, 12/25/25, 12/27/25, 12/29/25, 12/30/25, and 12/31/25, and no FSBS tests documented before breakfast on 1/1/26, 1/2/26, 1/3/26, 1/5/26, and 1/6/26. A blood glucose result of 256 mg/dl was documented on 1/6/26 at 8:30 AM. The facility’s policy on obtaining a fingerstick glucose level required the nurse to record blood sugar results in the medical record and promptly report results outside physician-ordered parameters to the supervisor and physician. During interviews and concurrent record reviews, a licensed nurse confirmed that the resident had an order starting 12/24/25 for FSBS checks before breakfast with instructions to report BG results greater than 200 mg/dl to the physician, and acknowledged that the ordered blood sugar checks were not completed for 11 out of 13 days between 12/24/25 and 1/6/26. The DON confirmed that breakfast trays were delivered between 7:00 AM and 8:00 AM, verified the missing FSBS tests for 11 of 13 days in that period, and confirmed that the elevated BG result of 256 mg/dl on 1/6/26 was not reported to the physician and no treatment for hyperglycemia was administered. The facility’s acute condition changes protocol required staff to monitor and document the resident’s progress and response to treatment so the physician could adjust treatment, but this monitoring and follow-up were not carried out as ordered for the resident’s blood glucose management.
Failure to Initiate Fall Prevention Care Plan After Resident Re-admission With Hip Fracture
Penalty
Summary
Surveyors identified a deficiency in care planning when the facility failed to develop a fall awareness and fall prevention care plan for a resident upon re-admission. Record review showed that on 12/17/25 the resident was found by a CNA lying on her back on the hallway floor, complaining of lower extremity pain, and was sent to the hospital for evaluation. The resident was re-admitted on 12/22/25 with diagnoses including fracture of the left femur, hip fracture, muscle weakness, kidney disease, and age-related osteoporosis. Nursing progress notes documented the re-admission with a left hip fracture diagnosis. During interviews and concurrent record reviews with a licensed nurse and the DON on 1/7/26, both confirmed that the resident’s clinical record did not contain a fall care plan. The licensed nurse stated that a fall care plan was important for resident safety and was part of the facility’s protocol after a fall. The DON stated that the care plan was used by all staff as a guide for resident care and acknowledged that the absence of a care plan meant nursing staff lacked guidance about the resident’s care. The DON also stated she expected staff to have initiated a fall care plan due to the resident’s fall history and risk of falls. Review of the facility’s Falls Management policy indicated that the facility’s process included evaluating, managing, and reducing falls, with licensed nurses documenting interventions and monitoring responses, but this was not implemented for the resident following re-admission.
Failure to Maintain Resident Privacy Due to Unauthorized Photography
Penalty
Summary
Staff members failed to maintain residents' rights to privacy when two certified nursing assistants (CNAs) took photographs of two residents and their rooms using personal phones without obtaining the residents' knowledge or consent. One resident, who was no longer at the facility at the time of review, was photographed in their room by a CNA, despite being unable to provide consent and without the responsible party being informed or asked for consent. The Director of Staff Development (DSD) confirmed that photographs were taken without proper authorization, acknowledging that this action violated the resident's privacy. In another instance, a CNA took photographs of a resident's colostomy bag, which was leaking and dirty, again without obtaining consent from the resident. The photographs were taken on the CNA's personal phone, and the DSD confirmed that consent should have been obtained prior to taking any photographs of the resident or their surroundings. Facility policy requires employees to treat residents with respect, dignity, and to maintain privacy and confidentiality, which was not followed in these cases.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care practices for residents requiring assistance with bowel and bladder management, catheter maintenance, and infection prevention.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the most recent federal recertification survey were readily accessible to residents, family members, and legal representatives. During a Resident Council Meeting, residents reported they were unaware of where to find the survey results and did not know that such results were available for them to read. Interviews with staff, including the Infection Preventionist (IP) and the administrator (ADM), revealed that staff were also unclear about the location of the survey results. The ADM indicated that the survey results binder was supposed to be by the front door, but upon inspection, the area was empty, and the binder was not present. The ADM stated it had been updated recently but was not available at the time of observation. Further, the Director of Nursing (DON) acknowledged that if the survey result binder was not easily available, residents would not be able to know the results from the last survey or what the facility was working on to address identified problems. The DON was unsure how long the binder had been unavailable. A review of the facility's policy confirmed that residents have the right to examine survey results, as guaranteed by federal and state laws. This deficiency affected a census of 75 residents and was based on direct observation, interviews, and record review.
Failure to Maintain Functional Call Light System for Resident Assistance
Penalty
Summary
The facility failed to maintain a functioning resident call light system, resulting in staff not being directly alerted to residents' requests for assistance. Observations showed that when a resident pressed the call light in their room, the only indication was a light above the door, with no audible or visual alert at the nurses' station or a centralized staff area. Multiple staff members, including licensed nurses, confirmed that the call light system had not been working properly for at least a year, and that staff were expected to visually check for call lights while walking the halls. During several observations, staff walked past rooms with active call lights without responding, and there were periods when no staff were present in the hallways or at the nurses' station to notice the call lights. The administrator and DON acknowledged the lack of a functioning call light board or alarm and confirmed awareness of the issue for several months. Facility policy required that residents have a means of communication with nursing staff and that call lights be answered within 3-5 minutes. However, observations documented call lights remaining unanswered for extended periods, including one instance where a call light was left on for approximately 18 minutes before being answered. Staff interviews confirmed that the lack of an audible or visual alert at the nurses' station made it difficult to respond promptly to residents' needs, and that the system had not been repaired despite being reported as nonfunctional.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Failure to Document and Provide COVID-19 Vaccine Education
Penalty
Summary
The facility failed to provide and document education regarding the benefits and potential side effects of the COVID-19 vaccine for three of five sampled residents. Interviews with the Infection Preventionist (IP) revealed that while the COVID-19 vaccine was offered upon admission and staff were expected to educate residents about the vaccine, there was no documented evidence in the clinical records of the three residents that such education was provided. The IP confirmed during record review that education was not given to these residents prior to vaccine administration. Review of the facility's policies indicated that residents should be provided with education about the risks and benefits of the COVID-19 vaccine before it is offered, and that this education, along with consent and vaccine administration, should be documented in the medical record. However, the immunization records for the three residents only indicated the date the vaccine was given, with no documentation of education or consent. The IP acknowledged that the lack of education could result in residents not being aware of what symptoms or side effects to report to staff.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear medical justification or were given medications that limited their functional abilities, contrary to regulatory requirements.
Failure to Update Smoking Assessment and Post Oxygen Signage
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who was initially assessed as a nonsmoker upon admission, was observed smoking unsupervised in the designated smoking area with cigarettes and lighters in her possession. The resident's smoking risk assessment had not been updated to reflect her current smoking status, and staff responsible for supervision left the area, leaving her unattended. Facility policy required smoking assessments to be updated at admission, quarterly, annually, and as needed, but this was not followed. Additionally, another resident receiving oxygen therapy did not have an 'oxygen in use' sign posted at the entrance to their room, as required by facility policy. Observations confirmed the resident was on oxygen via nasal cannula, but signage was missing, which staff acknowledged was necessary to alert others to the presence of oxygen. The Infection Prevention nurse confirmed the lack of signage and stated that the expectation was for licensed nurses to ensure the sign was posted, but this was not done. The facility's policy on oxygen therapy specified that 'oxygen in use' signs should be placed both inside and outside the room.
Failure to Follow Medication Hold Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to ensure safe monitoring and assessment of blood pressure and heart rate for a resident prescribed Midodrine, a medication used to treat low blood pressure. The physician's order specified that Midodrine should be held if the resident's systolic blood pressure exceeded 120 mmHg. Despite this, the medication was administered on seven occasions when the resident's systolic blood pressure was above the ordered threshold. This was confirmed through review of the resident's Medication Administration Record (MAR) and interviews with a licensed nurse and the Director of Nursing, both of whom acknowledged that the medication should not have been given under these circumstances. The resident involved had a medical history including hypertensive heart disease with heart failure and acute on chronic systolic congestive heart failure. The facility's policy required compliance with medication administration parameters and documentation of any medication errors, including notifying the physician and supervisor. However, there was no documentation in the resident's medical record of the seven medication errors, nor was the Director of Nursing made aware of these errors at the time they occurred.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals. No further details about specific residents, staff, or incidents are provided in the report.
Deficiency in Menu Planning and Nutritional Oversight
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met as outlined in their care plans. These deficiencies were observed through review of facility menus and dietary records, which showed lapses in menu preparation, adherence, and oversight by qualified dietary staff.
Failure to Accommodate Resident Dietary Preferences and Requirements
Penalty
Summary
During a lunch meal observation, two residents did not receive food and beverages in accordance with their documented dietary requirements and preferences. One resident, whose meal ticket specified 8 ounces of 2% milk as a beverage, did not receive the milk with their lunch. Another resident, who had a documented dislike of corn, was served coleslaw containing corn despite this preference being noted on their meal ticket. These discrepancies were identified through direct observation, review of meal tickets, and interviews with dietary staff. Interviews with the Dietary Supervisor and Registered Dietitian confirmed that kitchen staff are expected to follow meal tickets, and that residents' food preferences and dietary requirements should be honored. Facility policies reviewed indicated that food preferences are to be adhered to within reason, and substitutes should be provided for disliked foods. The failure to follow these procedures resulted in residents not receiving meals consistent with their documented needs and preferences during the observed meal service.
Failure to Provide Specialized Eating Utensils as Indicated on Meal Tickets
Penalty
Summary
The facility failed to provide specialized eating utensils to two residents during a lunch meal, despite documentation indicating the need for such devices. One resident, admitted with severe protein-calorie malnutrition and dysphagia, was observed receiving a regular plate and utensils, although their meal ticket specified a scoop plate and built-up utensils. The second resident, also with severe protein-calorie malnutrition and muscle weakness, received regular utensils instead of the required built-up utensils as indicated on their meal ticket. Observations confirmed that the kitchen staff did not follow the meal ticket instructions for these residents. Interviews with the Dietary Supervisor and a Licensed Nurse revealed that staff were expected to provide assistive devices as indicated on meal tickets, and that the omission was not in accordance with facility policy or physician orders. The Licensed Nurse confirmed that one resident had a physician order and care plan for special utensils, while the other did not. The Registered Dietitian also stated that kitchen staff should have followed the meal ticket instructions. Facility policy required that residents needing self-feeding devices receive them with each meal, as recorded on tray cards and diet profiles.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to ensure adequate hydration for two residents, as required by facility policy and each resident's care plan. Observations and interviews revealed that both residents did not have fluids available at their bedside, despite having no fluid restrictions and being identified as at risk for dehydration. Staff, including licensed nurses and certified nurse assistants, confirmed the absence of fluids and acknowledged that fluids should have been available and within reach at all times. Both residents' care plans and hydration risk assessments specifically included interventions such as keeping fluids in reach, encouraging oral fluid intake, and monitoring for signs and symptoms of dehydration. As a result of these failures, one resident exhibited dry mucous membranes, chapped lips, and dry, peeling skin on the left leg, while the other resident had dry mucous membranes, chapped and cracked lips, and concentrated dark amber urine. Staff interviews confirmed these were signs and symptoms of dehydration and, in one case, increased risk for urinary tract infection due to the presence of an indwelling catheter. The Director of Nursing stated that it was the facility's expectation for residents to always have fluids available and within reach, and that the process required CNAs to provide fresh fluids at the beginning of each shift and with each meal.
Failure to Provide and Document Required Medications for Two Residents
Penalty
Summary
The facility failed to ensure the provision and documentation of routine and emergency medications for two residents, resulting in deficiencies related to pharmaceutical services. One resident, admitted with chronic obstructive pulmonary disease (COPD) and dyspnea, did not receive a physician-ordered as-needed (PRN) Ipratropium-Albuterol inhaler due to the medication being unavailable from the pharmacy. The resident reported not receiving the inhaler since admission, despite experiencing episodes of shortness of breath. Review of the Medication Administration Record (MAR) confirmed that the inhaler had never been administered, and nursing staff verified that the medication was not present in the medication cart. Interviews with nursing staff and the Director of Nursing (DON) revealed that the process for following up with the pharmacy and notifying the physician or responsible party about unavailable medications was not followed, and there was no documentation of alternative arrangements or communication regarding the missing medication. Another resident, admitted with sepsis, cellulitis, and a wrist fracture, was prescribed intravenous (IV) antibiotics following hospital discharge. Upon admission, the resident required immediate administration of IV Cefazoline, which was obtained from the Emergency Kit (E-kit) due to pharmacy delivery timing. However, the removal of the antibiotic from the E-kit was not documented in the medication log, pharmacy E-kit slips, or progress notes. Staff interviews confirmed that the required documentation process, which includes filling out pharmacy slips and logging the removal to notify the pharmacy for restocking, was not completed. The facility's policy and procedure required this documentation to ensure accurate record-keeping and timely replacement of emergency medications. Both deficiencies were confirmed through interviews with staff and review of facility policies, which outlined the required steps for medication ordering, receiving, and emergency kit management. The DON and Director of Staff Development acknowledged that the expected procedures were not followed in these cases, resulting in the unavailability of a prescribed inhaler for one resident and a lack of documentation for the use of an emergency antibiotic for another.
Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
A resident with a history of chronic combined systolic and diastolic congestive heart failure was admitted to the facility and was observed receiving oxygen therapy at 2 liters per minute via nasal cannula. During interviews and record reviews, it was confirmed by both nursing staff and the Director of Nursing that the resident was on oxygen therapy as needed for shortness of breath. However, it was found that no care plan had been developed to address the resident's oxygen use, despite the resident's ongoing need for this intervention. The lack of a care plan for oxygen therapy was acknowledged by both the licensed nurse and the Director of Nursing, who confirmed that the facility's policy and procedure required a comprehensive, measurable, and time-framed care plan for each resident. The absence of this care plan meant that appropriate goals and interventions for the resident's oxygen therapy were not documented or communicated to staff, contrary to facility policy and professional standards of practice.
Failure to Complete Required AIMS Assessments for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to provide services that meet professional standards of practice for two residents who were prescribed antipsychotic medications. For both residents, the required Quarterly Abnormal Involuntary Movement Scale (AIMS) assessments, which are used to monitor for side effects of antipsychotic medications, were not completed. Specifically, one resident with diagnoses including severe unspecified dementia with psychotic disturbance, unspecified mood disorder, and unspecified psychosis had been taking Seroquel 50mg twice daily, but the AIMS assessment initiated was left completely blank, and no other AIMS assessments were found in the medical record. Another resident with diagnoses including vascular dementia, psychotic disorder with delusions due to a known physiological condition, mood disorder due to a known physiological condition with mixed features, major depression disorder unspecified, and anxiety disorder unspecified had been receiving Olanzapine 2.5mg daily, but their AIMS assessment was also left blank, with no other completed assessments found in the record. Interviews with licensed nursing staff and the Director of Nursing (DON) confirmed that both residents had been on antipsychotic medications for several months and that the AIMS assessments were incomplete or missing. The DON acknowledged that facility policy requires AIMS assessments to be performed quarterly for any resident on an antipsychotic and that these assessments had not been completed as required for the two residents. The failure to complete these assessments was confirmed through both record review and staff interviews.
Contradictory POLST and Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a resident's end-of-life wishes and emergent treatment preferences were accurately documented and consistent across medical records. Specifically, the resident's POLST (Physician Orders for Life Sustaining Treatment) form and the electronic medical record contained contradictory code status selections. The POLST form had both 'Do Not Attempt Resuscitation/DNR' and 'Full Treatment' options marked, which are mutually exclusive. The electronic physician's order also reflected this contradiction by listing the resident as DNR with full treatment. These inconsistencies were confirmed during interviews and record reviews with licensed nursing staff, who acknowledged that the documentation was confusing and could result in the resident not receiving care according to their wishes. The resident in question was admitted with multiple diagnoses, including cerebral infarction and vascular dementia. Interviews with the resident's representative clarified that the resident did not want CPR or any life-prolonging interventions if their heart or breathing stopped. The Director of Nursing confirmed that the POLST was completed incorrectly and was contradictory, acknowledging that such errors could lead to the resident receiving care that was not in line with their expressed preferences. Facility policy required review of POLST forms for validity upon completion, but this process failed to prevent the error.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Maintain Resident Dignity and Privacy for Catheter Care
Penalty
Summary
A deficiency was identified when a resident with a urinary catheter was observed to have their catheter drainage bag exposed and not placed in a dignity bag, as required for privacy and dignity. During an observation, the catheter bag was seen hanging on the side of the bed without a privacy cover. The resident had been admitted with diagnoses including acute cystitis without hematuria and generalized muscle weakness. Review of the clinical record confirmed the presence of the catheter, and interviews with staff revealed that the use of dignity bags was expected as part of catheter care. Certified Nurse Assistant (CNA) staff acknowledged that dignity bags are typically used but sometimes become displaced or are removed. Licensed nursing staff confirmed that the catheter bag should have a privacy cover and that its absence could lead to embarrassment for the resident. The Director of Nursing (DON) stated that the dignity cover may have been forgotten due to the recent admission. Facility policy requires all residents to be treated with respect and dignity, including the right to privacy and confidentiality, which was not upheld in this instance.
Failure to Provide Vaccine Education Prior to Pneumococcal Immunization
Penalty
Summary
The facility failed to provide education regarding the benefits and potential side effects of the pneumococcal vaccine to one resident prior to administration. Specifically, the clinical record for the resident did not contain documented evidence that education was provided before the resident received the PCV20 (Prevnar 20) vaccine. During interviews, the Infection Preventionist (IP) confirmed that education should be given to residents before vaccination, including information on the indication for the vaccine, possible side effects such as inflammation, pain, fever, and diarrhea, and that this education should be documented in the resident's progress notes. However, upon review, the IP acknowledged that there was no documentation or evidence that this education was provided to the resident in question. The lack of documented education meant the resident was not fully informed prior to receiving the vaccine, which is a violation of the resident's right to make an informed choice about their care. The facility's policy on resident rights, as well as federal and state laws, require that residents be informed and participate in their care planning and treatment. The IP also stated that not providing education could result in residents being unaware of what symptoms or side effects to report to staff.
Failure to Prevent Elopement and Ensure Safety for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with cognitive impairments and a history of wandering. Both residents had physician orders and care plans requiring the use of Wander Guard devices, with checks for placement and functionality to be performed and documented every shift. However, multiple instances were identified where these checks were not documented for both residents across several shifts, as confirmed by the Director of Nursing (DON) and review of the Medication Administration Records (MARs). The DON acknowledged that facility policy was not followed regarding these required checks. Additionally, the facility did not complete required elopement risk assessments for the two residents on a quarterly basis, as stipulated by facility policy and confirmed by the DON. One resident had not been reassessed for elopement risk since admission, and the other had not been reassessed since a previous quarterly assessment, despite both being identified as high risk for elopement. After one resident exited the facility unsupervised and was found in the street, there was no documentation of a change in condition, no care plan update, and no reassessment for elopement risk, contrary to facility policy. The incident involving the resident who exited the facility revealed further lapses in supervision and documentation. Staff interviews confirmed that the resident was found outside by a staff member, but it was unclear how long the resident had been outside or how the exit occurred. There was no documentation in the electronic medical record regarding the incident, and the required follow-up assessments and documentation were not completed. Furthermore, the Maintenance Supervisor reported that weekly checks of the Wander Guard system were performed but not documented, which was inconsistent with best practices and manufacturer recommendations.
Improper Transfer Technique Results in Resident Rib Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident with osteoporosis and muscle weakness from a shower chair to her bed using a one-person 'bear-hug' technique, rather than the required two-person assist with a gait belt. The resident's care plan and Minimum Data Set (MDS) both indicated the need for substantial/maximal assistance and a two-person transfer due to her inability to bear weight and her high risk for fractures. However, the CNA performed the transfer alone and without a gait belt, contrary to facility policy and training. The incident resulted in the resident experiencing acute pain and a subsequent diagnosis of a right seventh rib fracture, as confirmed by emergency department evaluation. Interviews with staff revealed that the CNA was aware of the resident's fragile condition and had been trained not to use a hugging technique for transfers. The occupational therapist and director of staff development both confirmed that the proper method for transferring such residents involved two staff members and the use of a gait belt, and that hugging was never an appropriate or safe transfer method. Further review of the resident's records showed a lack of clear, accessible documentation in the electronic health record regarding the required transfer method, which contributed to the improper transfer. Staff interviews indicated confusion or lack of access to up-to-date transfer instructions, despite the resident's documented need for two-person assistance. The facility's policy explicitly required the use of a gait belt for dependent residents to prevent injuries, but this was not followed in the incident.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision to protect a resident from physical abuse by another resident. Resident 39, who has multiple sclerosis and limited mobility, was attacked in his room by Resident 79, who has a history of severe mental illness and violent behavior. Resident 79 entered Resident 39's room and struck him in the face multiple times, resulting in facial bruising, a cut lip, and head pain for Resident 39. Resident 79's clinical records revealed a pattern of violent behavior, including attacking staff members and exhibiting paranoid delusions. Despite these documented incidents, Resident 79 was not adequately supervised, leading to the assault on Resident 39. The facility's policy on abuse prevention and resident safety was not effectively implemented, as evidenced by the failure to prevent Resident 79 from accessing Resident 39's room and causing harm. Interviews with staff and other residents indicated a general sense of fear and lack of safety due to Resident 79's behavior. The facility's administrator acknowledged the attack but did not classify it as abuse, despite the facility's policy defining abuse as the willful infliction of injury. The incident highlights a significant deficiency in the facility's ability to protect residents from abuse and ensure their safety.
Inadequate Dietary Supervision and Oversight
Penalty
Summary
The facility failed to ensure that a Dietary Supervisor (DS) was onsite on a full-time basis, as required, to manage the day-to-day operations of the food and nutrition services. Although the DS was employed full-time, she was only present at the facility three days a week, working Monday, Tuesday, and Thursday. This arrangement was made after the DS retired and was called back by the administrator to help, with an agreement to work part-time. Consequently, the kitchen was left without proper supervision on Wednesdays, Fridays, and weekends, during which the Cooks were tasked with overseeing the kitchen staff, despite this not being part of their job description. The Registered Dietitian (RD), who worked only two days a week, also did not provide adequate oversight or consultation to the DS, as her time was primarily consumed by clinical duties. The lack of consistent oversight by qualified staff led to potential lapses in food and nutrition services, including meal distribution accuracy and safe food handling and sanitation. Interviews with kitchen staff revealed a lack of structure, organization, and consistency in the kitchen operations, with staff expressing the need for more guidance. The RD confirmed that she rarely checked the kitchen and had not conducted any monthly kitchen sanitation audits, leaving the responsibility to the DS, who was not present full-time. This deficiency affected the food services provided to 81 residents who relied on the kitchen for their meals.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies observed during a survey. Several tray line pans and serving utensils were found stacked and stored while still wet, which was confirmed by the Dietary Supervisor and Registered Dietitian as a practice that could promote bacterial growth. Additionally, a significant number of food items in the reach-in refrigerators were outdated or incorrectly labeled, including iced coffee, tuna, applesauce, and various salads, which were acknowledged by the Dietary Supervisor as expired and improperly managed. Further observations revealed stale and expired produce in the walk-in refrigerator, including cucumbers, lettuce, tomatoes, and green onions, which were confirmed by the Dietary Supervisor as spoiled and needing disposal. The ice machines at nursing stations one and two were not cleaned and sanitized according to the manufacturer's guidelines, with black and slimy substances found on the ice baffle. The Maintenance Supervisor and Maintenance Assistant acknowledged the oversight in the cleaning process, which did not include the necessary sanitizing step. Additional issues included unclean microwaves with chipping interior linings, improper thawing of meat by a cook, and a food processor with accumulated black substances. The facility also failed to monitor temperatures and label food items in residents' refrigerators, leading to expired and unlabeled food being stored. Staff members, including a cook and a dietary aide, demonstrated a lack of knowledge in food cooling processes and manual dishwashing procedures, respectively, indicating a need for further training and adherence to established guidelines.
Improper Garbage Disposal
Penalty
Summary
The facility failed to maintain a clean environment for residents and visitors by not properly securing one of the three garbage disposal bins located outside near the kitchen. During an observation, it was noted that the dumpster lid was not securely closed, leaving bags of trash exposed. This oversight was acknowledged by the Dietary Supervisor, who confirmed that the lid should always be tightly closed to prevent attracting pests and rodents. The Registered Dietitian also emphasized the importance of keeping garbage bins closed to avoid pest and rodent infestations. The facility's policy, as outlined in the departmental policy and procedure titled 'Miscellaneous Areas,' mandates that all food waste must be placed in sealed, leak-proof, non-absorbent, tightly closed containers to prevent nuisances or unsightliness. Additionally, the 2022 FDA Food Code specifies that outside receptacles for refuse containing food residue must have tight-fitting lids, doors, or covers. The failure to adhere to these guidelines posed a potential risk for pest infestation and disease spread within the facility.
Inadequate Training in Food Service Procedures
Penalty
Summary
The facility failed to ensure that two food service personnel were adequately trained to safely and effectively carry out the functions of the food and nutrition services. Dietary Aide 1 was unable to correctly verbalize the process of manual dishwashing using a two-compartment sink. She initially stated the process involved sanitizing, rinsing, and washing, but later corrected herself to washing, rinsing, and sanitizing with prompting. However, she was unable to provide the correct water temperatures for washing and rinsing or the temperature and immersion time for the sanitizer. It was revealed that she had not attended the relevant training session, and her employee file did not contain a food service handling certificate. The facility's policy required specific temperatures and a bleach solution for sanitizing, which DA 1 was not aware of. Additionally, another staff member, CK 2, improperly thawed meat by submerging it in hot water, contrary to the facility's policy which required thawing under running cool water. CK 2 admitted to knowing the correct procedure but was unaware that the water needed to be running. She also had not received training on thawing meats, and her food handler permit was expired. The facility's policy specified that meat should be thawed under running water at a temperature of 70 degrees Fahrenheit or lower. Both the Dietary Supervisor and Registered Dietitian confirmed the deficiencies in training and knowledge among the staff.
Dietary Non-Compliance in Meal Service
Penalty
Summary
The facility failed to adhere to the prescribed dietary requirements for several residents during a lunch meal service. Sixteen residents on a consistent carbohydrate (CCHO) diet received diet gelatin without the whipped topping, contrary to the menu specifications. Twelve residents on low fat/low cholesterol and 2 grams sodium diets were served salad with regular dressing instead of the required fat-free or sodium-free dressing. Additionally, six residents on a pureed texture diet did not receive pureed salad as indicated on the menu. Resident 38, who required a CCHO, 2 grams sodium, and double meat diet, was served only a single portion of meat. Resident 55, on a regular diet with chopped meat and finger foods, received a turkey sandwich and other items not listed on the menu spreadsheet. Further discrepancies included Resident 35, who was on a dysphagia mechanical texture diet, receiving chopped salad instead of pureed salad. Resident 20, on a fortified regular diet with small portions, did not receive the extra gravy on the chicken as required for fortification. These failures were identified through observation, interviews, and record reviews, indicating a lack of adherence to the planned menu and dietary requirements, potentially compromising the medical and nutritional status of 38 residents.
Deficiencies in Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to ensure safe pharmaceutical services for its residents, as evidenced by several deficiencies. Firstly, the disposition of non-controlled prescription medications was not documented. During an inspection of the medication room, discontinued and unusable prescription medications were found stored without any record of their destruction. The Charge Nurse was unaware of who was responsible for destroying these medications and could not locate any documentation. The Director of Nursing indicated that the night shift was supposed to handle the destruction and documentation, but this was not being done. Additionally, the emergency kits (E-kits) at Nurses Station 1 were not properly managed. The refrigerator E-kit was found unsealed and open, with no documentation of the medication removed. The oral medication E-kit had been opened and left unsealed for six days without being restocked. The Licensed Nurse present during the inspection was unsure of when the kits were opened and acknowledged issues with the re-seal tags. The facility's policy required documentation and immediate notification to the pharmacy when medications were removed from the E-kits, but this was not followed. Furthermore, the facility did not consistently sign or review prescription drug delivery manifests upon delivery. The Charge Nurse confirmed that the delivery slips were not consistently signed, which was necessary to verify the accuracy of the medications received. Additionally, there was a discrepancy in the documentation of narcotic medication for a resident. The Controlled Drug Record showed that oxycodone was signed out on several occasions, but there was no corresponding documentation in the Medication Administration Record. The Director of Nursing could not determine why the administration was not recorded, and the nurses involved were no longer employed at the facility.
Failure to Monitor Vital Signs for High-Risk Medications
Penalty
Summary
The facility failed to ensure proper monitoring and adherence to physician-ordered vital sign parameters for residents on high-risk medications. Resident 21 was administered three blood pressure medications on two occasions despite systolic blood pressure readings being below the physician-set parameters. This oversight occurred on specific dates when the systolic blood pressure was documented at 106 and 107, below the hold threshold of 110. Resident 77, who was on multiple medications for congestive heart failure, experienced a similar issue. On a particular date, despite a systolic blood pressure reading of 105, which was below the hold parameter, three medications were administered. This resulted in the resident experiencing very low blood pressure and dizziness, necessitating a transfer to the emergency room later that day. Resident 13, who was on medications for heart failure and irregular heart rhythm, also received medications despite vital signs being below the hold parameters. On two separate occasions, the resident's pulse was documented at 57 and 58, below the hold threshold of 60, yet the medications were administered. Interviews with staff revealed a lack of adherence to the facility's policy requiring vital sign checks and physician notification when parameters are not met.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure the safe use and monitoring of psychotropic medications for three residents, leading to deficiencies in care. Resident 21 was prescribed multiple mood-altering medications for anxiety, depression, and behavioral disturbances related to dementia. However, the facility did not document any non-pharmacological interventions for behavior modification, as required. Additionally, the behavior monitoring for Resident 21 was non-specific, and the behaviors did not pose a danger to self or others, indicating a lack of appropriate assessment and justification for the continued use of psychotropic medications. Resident 37 was also prescribed psychotropic medications for anxiety, depression, and schizoaffective disorder. Similar to Resident 21, there was no documentation of non-pharmacological interventions for behavior modification. Furthermore, Resident 37's use of a PRN anti-anxiety medication continued beyond 14 days without an assessment of its use and justification for its continuous need. The interdisciplinary team meetings did not address mental health issues and medication use or their effectiveness, highlighting a gap in coordinated care. Resident 58 was prescribed an antipsychotic medication on a PRN basis without a limit on its duration of use. The facility failed to document any interdisciplinary team meetings to address the use of psychotropic medications for Resident 58. The facility's policy required regular review of psychotropic medication use, but this was not consistently followed, as evidenced by the lack of documentation and assessment of the continued need for PRN medications. The facility's consultant pharmacist had previously educated the staff on regulatory requirements, but these were not adhered to, resulting in the deficiencies noted in the report.
Failure to Conduct Interdisciplinary Care Conferences
Penalty
Summary
The facility failed to honor residents' rights to participate in care conferences, which are essential meetings between healthcare professionals and residents or their families to discuss and plan individualized care. This deficiency was identified for five residents, who did not have their quarterly and comprehensive care conference meetings held as required. Interviews with residents revealed that they were either unfamiliar with care conferences or had not attended any since their admission to the facility. Record reviews confirmed that the interdisciplinary team (IDT) care conference records were incomplete, with only dietary and activities sections filled out, and lacked signatures from all required IDT members. The Social Services Director (SSD) admitted to not scheduling or coordinating IDT care conferences as required. Instead, the SSD met with residents individually and considered these meetings as care conferences, without involving the full IDT. The SSD acknowledged that all IDT members should meet together with residents and families to discuss all aspects of care, but this was not happening. The Registered Dietitian and MDS coordinator also confirmed that they did not attend IDT care conferences and that each department updated care plans independently, rather than as a coordinated team effort. Further interviews with the Director of Nursing (DON) and the facility Administrator confirmed that the facility's policy for IDT care conferences was not followed. The facility's policy required that care conferences be held within seven days of admission and then quarterly, with participation from all relevant disciplines. However, no such meetings were documented for the residents in question. The Administrator emphasized the importance of these meetings for coordinating care and ensuring all departments are aware of the residents' health and goals, but acknowledged that this process was not being implemented as intended.
Failure to Document and Match End-of-Life Wishes
Penalty
Summary
The facility failed to ensure that the end-of-life wishes and emergent treatment desires of six residents were accurately documented and available to staff. Specifically, Resident 70's POLST and documented code status did not match, leading to confusion among staff about whether to perform CPR. The POLST indicated a DNR status, while the physician's order stated a full code status. This discrepancy was acknowledged by a licensed nurse who found the information contradicting and confusing, highlighting the need for clarification to ensure the resident's wishes were honored. Additionally, the facility did not have copies of the Advance Directives for Residents 10, 21, 61, 70, 75, and 239 in their medical records. Interviews with the Business Office Manager and other staff confirmed that although these residents had executed Advance Directives, no attempts were made to obtain or document these directives in the residents' records. This lack of documentation meant that staff did not have access to critical information regarding the residents' end-of-life treatment preferences and designated decision-makers. The Administrator and Director of Nursing acknowledged the importance of having matching POLST and physician orders, as well as the presence of Advance Directives in medical records to ensure residents' wishes are respected. The facility's policy required that Advance Directives be obtained and placed in the medical record, but this was not followed, as evidenced by the absence of these documents in the residents' files. The failure to adhere to these policies resulted in the potential for residents' emergency treatment wishes not being honored.
Failure to Maintain Professional Standards in Glucometer Testing and Medication Administration
Penalty
Summary
The facility failed to maintain professional standards of quality in two key areas. Firstly, the glucometer quality control (QC) test logbook at Station 1 was not consistently completed for all active glucometer devices. During an interview and record review, it was revealed that some required nightly QC tests were not performed, and entries lacked QC lot numbers and expiration dates for the control solution. The Director of Nursing (DON) confirmed that the process for glucometer QC testing and recording was not followed as expected, which included recording device numbers, QC results, expiration dates, and the staff performing the tests. This was contrary to the facility's policy and procedure, which required nightly QC checks to ensure accurate blood glucose testing. Secondly, Resident 21's medication administration was mishandled. The resident, who was admitted with dementia and anxiety, was observed with a medication cup containing multiple pills left on their bedside table. The resident had requested the Licensed Nurse (LN) to leave the pills so they could take them one at a time. However, LN 2 acknowledged that this was a mistake, as they should have observed the resident taking the medication or removed the cup to prevent potential medication errors. The DON confirmed that the facility's policy, which required LNs to observe residents taking their medications and not leave medications unattended, was not followed. These deficiencies had the potential to result in inaccurate blood glucose tests and medication errors, which could affect the residents' health outcomes. The facility's policies and procedures were not adhered to, leading to these lapses in care quality and safety.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to ensure safe storage and handling of medications and medical supplies, as observed in various areas including the medication cart, treatment cart, refrigerator, and medication room. At Station 1, the medication refrigerator storing insulin and vaccines had heavy frost, and the temperature was not documented twice daily as required. The facility's policy did not specify who was responsible for defrosting the refrigerator, and the CDC guidelines for vaccine storage were not followed, which could affect the potency of the medications. Additionally, expired glucometer control solutions and test strips were found in the medication room at Station 1, and the emergency kits were stored in a cabinet that could not be locked due to a malfunction. The facility's policy on emergency kits required them to be kept secure and checked periodically, but this was not adhered to. At Station 2, the treatment cart contained expired topical drugs and opened sterile products, which should not have been reused due to the risk of infection. Furthermore, hazardous medications were not stored safely to prevent touch contamination. At Station 1, a nurse handled hazardous drugs without gloves, and the medication cart at Station 2 stored hazardous drugs without proper containment. The facility's policy required hazardous drugs to be handled with personal protective equipment, but staff were not aware of these requirements. The Director of Nursing acknowledged the importance of handling hazardous drugs properly, but the facility's practices did not align with their policies or federal guidelines.
Infection Control Deficiencies in Glucometer Use and Expired Hand Sanitizers
Penalty
Summary
The facility failed to adhere to safe infection prevention practices during a medication pass observation involving the use of a glucometer. A licensed nurse conducted finger stick blood glucose tests on two residents without cleaning and disinfecting the glucometer between uses. The nurse acknowledged not following the required two-step cleaning and disinfection process, which involves removing visible dirt and blood before disinfecting the device with a disinfectant wipe for a minimum of two minutes. This oversight was confirmed by the Infection Preventionist and the Director of Nursing, who both stated that the glucometer should be cleaned and disinfected between residents according to the manufacturer's guidelines and facility policy. Additionally, the facility was found to have nine expired hand sanitizer bottles in active use across various locations, including the nurse's station and isolation carts. These expired sanitizers were confirmed by the Central Supply and Maintenance Supervisor, who acknowledged that expired hand sanitizers lose their efficacy. Certified Nurse Assistants reported using these hand sanitizers before and after patient care, indicating a reliance on potentially ineffective infection control measures. The Infection Preventionist and Director of Nursing both confirmed that expired hand sanitizers should be discarded and that all items should be current according to manufacturer guidelines. The facility's Enhanced Barrier Precautions Policy also mandates the provision of alcohol-based hand rubs in and outside resident rooms, highlighting the importance of maintaining effective infection control supplies.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
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