Playa Del Rey Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Playa Del Rey, California.
- Location
- 7716 Manchester Avenue, Playa Del Rey, California 90293
- CMS Provider Number
- 555004
- Inspections on file
- 61
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Playa Del Rey Center during CMS and state inspections, most recent first.
A resident with a history of stroke, hemiplegia, and hemiparesis, who was cognitively intact and required assistance with eating, had a care plan identifying nutritional risk related to cardiac disease, diet restrictions, and recent hospitalization, with a goal of consuming 75% of three daily meals and an intervention to monitor and document meal intake. Review of the ADL Meal Log showed multiple missing entries for several breakfasts, lunches, and dinners, and a CNA acknowledged that staff did not document how much the resident ate for those meals. An LVN confirmed that the care plan requirement to monitor and document intake for three meals daily was not followed, and the DON verified that progress notes did not include reasons for missed meals or incomplete intake documentation, despite facility policies requiring comprehensive care planning and recording meal consumption and refusals.
A resident with a history of stroke, severe cognitive impairment, and significant ADL and mobility assistance needs was not accurately identified as a fall risk on admission, and no specific fall risk care plan was developed. The DON later acknowledged that the admission fall risk assessment should have reflected the resident’s confusion, impaired balance, and predisposing disease, which would have triggered fall precautions. After the resident sustained unwitnessed falls from bed on two occasions, care plan updates were limited to existing measures such as low bed, floor mat, and call light within reach, without adding new interventions, and an LVN confirmed there was still no dedicated fall risk care plan in place.
A resident with hemiplegia, aphasia, and difficulty walking, but intact cognition, left the facility without being assessed by nursing staff, without an accompanying person as required by a physician’s order, and without signing the Out On Pass log. Staff interviews revealed that residents are expected to sign out at the nursing station and that the OOP log contained no entry for this resident on the day in question. An LVN confirmed no pre-departure assessment was completed despite the order requiring accompaniment, and an activities assistant reported seeing the resident alone at a nearby bus stop and did not notify nursing. The DON verified that the facility’s OOP policy requires a licensed nurse to assess the resident and document departure details, including the accompanying person, destination, and expected return time, which did not occur in this instance.
A CNA exited a resident room wearing a used gown and discarded it in a trash bin across the hallway instead of in a designated trash bin inside the room. In interviews, the CNA acknowledged that PPE should be discarded inside the room and that failure to do so could increase the risk of cross-contamination and make residents sick. The IPN confirmed that PPE is required to be discarded in designated in-room trash bins to prevent spread of infection, and facility policy states that staff receive training on proper donning, use, and disposal of PPE.
A resident with intact cognition and decision-making capacity was admitted with personal belongings, but staff did not complete the required Inventory of Personal Effects at admission, did not label the resident's clothing, and did not document the items brought in. Weeks later, an inventory form listed various belongings but did not reflect an admission inventory. The resident reported that bags of clothing, including favorite garments, went missing during the stay and stated that no personal inventory form was provided. A CNA confirmed that CNAs and licensed nurses are responsible for documenting residents' personal items on the inventory form upon arrival and updating it with any changes.
A resident with anxiety and depression had a PRN order for alprazolam 0.5 mg daily for episodes of inability to relax, but the facility failed to ensure the medication was available for use. The MAR showed no alprazolam administration over an extended period, and the resident reported requesting the medication multiple times and being told by an LVN it was not available, with non-pharmacological interventions offered instead. The pharmacist stated she received the alprazolam order but could not dispense it without a required handwritten physician signature and that staff did not follow up with the pharmacy for several days. Alprazolam was not stocked in the e-kit, and nursing leadership acknowledged that PRN medications were supposed to be available within two days of admission and that the facility’s medication administration policy for safe and timely administration could not be followed in this case.
A newly admitted resident who had recently undergone hip surgery did not have a baseline care plan developed within 48 hours as required by facility policy. The resident required significant assistance with ADLs, including toileting, bathing, and transfers, and was being monitored for pain and anticoagulant therapy. Staff confirmed the delay in care planning, which meant the care team may not have been fully informed of the resident's immediate needs.
A resident admitted with a hip surgical wound did not receive required monitoring and assessment for infection and wound complications. Nursing staff failed to document daily and weekly wound checks, did not assess the wound during episodes of reported pain, and only observed the dressing rather than the incision itself. The resident's follow-up with the surgeon was delayed, and the wound was not evaluated by a specialist until after dehiscence occurred, resulting in the resident seeking emergency care for infection.
A resident recovering from hip surgery did not receive required non-pharmacological pain interventions as ordered by the physician, and was administered Tramadol outside of prescribed parameters, with staff failing to document pain assessments and interventions according to facility policy.
Two residents with no dietary restrictions or dislikes did not receive the pork sausage patty listed on their meal tickets and the approved menu during breakfast. Both residents had medical conditions requiring adequate protein and calorie intake, and their trays were missing the specified item. Dietary and nursing staff confirmed the omission and acknowledged that the trays should have matched the meal tickets.
A resident with documented dislikes for orange juice and hot cereal was served both items on her breakfast tray, despite clear indications on her Dietary Profile and Meal Ticket. The resident, who was cognitively intact and able to communicate her preferences, reported the issue to staff, but only the orange juice was removed. The facility's policy requiring alternative selections for refused foods was not followed, resulting in the resident feeling angry and distressed.
A resident's medical records contained multiple documentation errors, including conflicting information about the surgical site location, misinterpretation of clinical terms, and incorrect timing of wound dehiscence. These inaccuracies were confirmed by both the DON and the treatment nurse, and did not meet the facility's standards for accurate nursing documentation.
A resident who was dependent on staff for toileting and personal hygiene was found lying in bed with a soaked diaper and wet bed linens, having not received morning care or a diaper change. The CNA acknowledged not checking the resident's diaper at the start of the shift, despite the care plan and facility policy requiring regular perineal care to maintain cleanliness and prevent complications.
The facility did not post current Direct Care Service Hours Per Patient Day (DHPPD) information as required, with the posted data found to be three days old. The Director of Staff Development confirmed the information was outdated and should be updated daily, in accordance with facility policy requiring daily posting of nurse staffing data for each shift.
Two residents' medications and supplements were not properly labeled: one resident's supplements were stored with only a room number as an identifier, and another resident's morphine was found with a medication label belonging to a different, discharged resident. Staff confirmed that all medications and supplements should be labeled with the resident's name and date of birth, in accordance with facility policy.
The facility did not update physician orders after receiving a telephone order to change the medication administration route for a resident with a g-tube, and also failed to complete an initial skin assessment for another newly admitted resident with multiple health conditions. These actions resulted in incomplete medical records and potential confusion for staff regarding care procedures.
A LVN was observed removing and discarding a used PPE gown in a hallway linen hamper instead of inside a resident's room, contrary to facility policy and infection control protocols. Staff interviews and policy review confirmed that used PPE should be disposed of in the resident's room to prevent cross contamination.
The facility did not meet the required minimum of 80 square feet per resident in 23 multiple occupancy rooms. Although residents were observed to have space for movement and personal property, facility records and a waiver request confirmed that these rooms were below the required size standard.
Two residents with physical limitations were not provided access to the weekly menu or alternative meal choices, as menus were only posted outside the kitchen and not made available to those unable to access them. Both residents, who had decision-making capacity, were unaware of their food options and reported not being offered choices, resulting in them eating only what was served.
A resident with severe cognitive impairment and multiple diagnoses was found to have their call light out of reach while in bed. Staff confirmed the call light was not accessible and acknowledged the importance of ensuring it is within reach, in accordance with facility policy.
A resident with dysphagia and a g-tube had a change in physician orders allowing medications to be taken orally, but the care plan was not updated to reflect this change. The care plan continued to address swallowing food and drinks but did not include interventions for oral medication administration, despite the resident's ongoing risk for swallowing difficulties. Staff and physician interviews confirmed the care plan was not revised, which could cause confusion.
A resident with a history of syncope and hypertension received losartan despite physician orders to hold the medication if systolic blood pressure was below 110 mmHg. Documentation showed the medication was administered on two occasions when the resident's blood pressure was below the specified threshold, contrary to facility policy and physician instructions.
A resident with significant physical and cognitive impairments was not assisted out of bed during mealtimes, despite a physician order and facility policy requiring such support. Staff were unaware of the order, and the care plan did not include this intervention, resulting in the resident consistently eating meals in bed.
A resident with atrial fibrillation and heart failure was prescribed amiodarone and carvedilol, and the pharmacist recommended monitoring for bradycardia due to the combined effects of these medications. However, there was no documentation that a physician reviewed or responded to this recommendation, as required by facility policy. The MRR was not reviewed by the responsible RN, and the DON had resigned, resulting in the recommendation not being communicated to the physician.
A resident with hypertension, cardiac arrhythmia, and hyperkalemia did not receive clonidine as ordered for elevated systolic blood pressure on 33 occasions. Although BP was checked as required, the MAR showed the medication was not administered or documented when indicated, and an LVN confirmed the omission. Facility policy required administration and documentation per physician orders, which was not followed.
A resident with mental health diagnoses experienced repeated verbal outbursts and threatening behavior from a roommate with a history of psychiatric disorders. Despite a care plan requiring one-to-one supervision for the roommate, staff left the resident unsupervised, allowing an incident where the roommate yelled, touched the resident's shoulder, and threatened with a butter knife. This failure to follow the facility's abuse policy resulted in the resident feeling unsafe and experiencing mental abuse.
A resident with multiple chronic conditions developed a right femur fracture of unknown origin, which was identified after complaints of increased pain. The resident, who was cognitively intact, denied any fall, abuse, or injury, and staff interviews confirmed no known cause. Despite facility policy requiring reporting of unusual occurrences, the incident was not reported to the state agency, as the Administrator determined the fracture was pathological and not of unknown origin.
A resident with impaired cognition and mobility, using a low air loss mattress (LALM), was being changed by a CNA who did not set the mattress to static mode or use the required two-person assist, resulting in the resident rolling off the bed and falling. Facility policy and staff interviews confirmed these safety steps were necessary to prevent such incidents.
A nurse failed to document the administration of seven scheduled medications for a resident with stroke, hemiplegia, and diabetes, despite facility policy requiring immediate documentation in the MAR. The nurse admitted the medications were given but not recorded due to being busy, resulting in no indication in the record that the resident received the medications.
A resident with diabetes and impaired cognition did not receive a scheduled dose of Lispro insulin on time because an LVN was busy, as confirmed by review of the MAR and staff interview. Facility policy required medications to be given within one hour of the scheduled time, but this was not followed, resulting in a medication error.
A resident with an indwelling catheter and obstructive uropathy experienced ongoing pain due to improper catheter management, which was reported to CNAs and LVNs but not addressed for several days. The pain interfered with participation in PT and daily activities, and pain medication was not administered as ordered. Staff interviews and record reviews confirmed the resident's pain was not managed according to facility policy.
A resident with quadriplegia and a suprapubic catheter did not receive a scheduled catheter lavage as ordered, despite repeated requests throughout the day. Due to staff shortages and competing priorities, the procedure was delayed for several hours, leading the resident to experience abdominal spasms and discomfort.
A resident with an indwelling Foley catheter and a history of obstructive uropathy repeatedly reported penile pain, which was not thoroughly assessed or managed by staff. Despite orders for as-needed acetaminophen, pain medication was not consistently administered, and the catheter was observed to be improperly secured, causing discomfort. The resident's pain led to refusal of therapy, and staff interviews confirmed a lack of timely pain assessment and intervention.
Nursing staff did not demonstrate competency in securing a Foley catheter for a resident with urinary tract conditions, resulting in several days of pain and discomfort. The resident repeatedly reported pain, and family members observed the catheter pulling. Staff were unable to properly secure the catheter due to lack of knowledge about the securing device, leading to ongoing irritation at the insertion site.
A resident with a history of depression and anxiety disorder experienced increased confusion, which was observed by a CNA and should have triggered a Stop & Watch notification. However, the CNA did not inform the charge nurse, and no documentation or notifications were made to the physician or responsible parties, despite facility policy and the resident's care plan requiring such actions.
Nursing staff failed to follow physician orders for medication administration and monitoring for two residents. In one case, an LVN did not check a resident's blood pressure in the required supine position before giving Droxidopa. In another, blood sugar checks were not performed or documented before insulin administration as ordered. The DON confirmed these lapses, and facility policy requires staff to demonstrate competency in such procedures.
A nurse failed to perform hand hygiene after removing gloves and before donning new gloves while caring for a resident who was totally dependent for ADLs and had multiple complex medical conditions. The nurse and DON both acknowledged that hand hygiene should have been performed, as required by facility policy.
A resident with a full code status was found unresponsive and staff failed to follow emergency procedures, including immediate activation of code blue, checking vital signs, and use of the AED. The CNA left the resident unattended to notify nurses, and although CPR was started, the AED was not used due to lack of staff training. This resulted in the resident's death and placed other full code residents at risk.
Three residents with significant physical and/or cognitive impairments were found with call lights out of reach, including one with hemiplegia and blindness, another with cerebral ischemia and muscle weakness, and a third with similar dependencies. Staff interviews and facility policy confirmed that call lights should be accessible at all times, but observations showed they were not, requiring staff intervention to correct placement.
A resident with diabetes and a history of refusing blood sugar checks was not monitored for signs and symptoms of hypoglycemia or hyperglycemia, despite physician orders and care plan interventions. Documentation and staff interviews confirmed that required monitoring and documentation were not performed, and the resident was later found in cardiac arrest with a critically high blood sugar level.
A resident with multiple medical conditions did not receive wound care as ordered by the physician, including the application of urea cream and wrapping of both lower extremities. The responsible LVN did not document the treatment in the TAR for several days, and both the LVN and DON confirmed that the care was not provided or recorded as required by facility policy.
A resident with a suprapubic Foley catheter was found to have cloudy, amber urine with sediments in the drainage bag. Nursing staff observed these signs but did not follow established protocols for assessment, physician notification, and specimen collection, resulting in a failure to ensure the resident was free from signs of urinary tract infection.
The facility failed to ensure timely medication administration for two residents due to insufficient staffing. One resident reported delays in receiving pain medication, while another experienced significant delays in scheduled medications. LVNs cited high resident numbers and frequent interruptions as reasons for the delays. The facility's policy requires sufficient staffing, but current levels were inadequate.
The facility failed to administer medications on time and as prescribed to several residents, with some medications being crushed without a physician's order. Staffing issues and frequent interruptions during medication passes contributed to these deficiencies.
A resident's medications were improperly administered by crushing them together without a physician's order, including an extended-release medication, in an LTC facility. The resident, with conditions such as hypertension and atrial fibrillation, preferred crushed medications for easier swallowing. However, the facility's pharmacy consultant confirmed that one medication should not be crushed, highlighting a failure in adhering to medication management protocols.
A facility failed to create a baseline care plan for a resident with diabetes within 48 hours of admission, as required by policy. The resident, admitted with type 2 DM, endocarditis, and chronic kidney disease, did not have a timely care plan, leaving staff without guidelines for managing the resident's diabetes. The DON acknowledged the oversight, which was contrary to the facility's policy.
A resident with diabetes receiving insulin injections did not have physician orders for blood sugar monitoring, as required by their care plan. The resident was admitted with conditions including diabetes and chronic kidney disease, but their medication administration record showed no blood sugar monitoring. The deficiency was noted when the resident became unresponsive with low blood sugar, necessitating hospital transfer. The DON confirmed the absence of monitoring orders and initial assessment, contrary to facility policy.
A resident with Influenza A and asthma was not properly monitored for respiratory rate, temperature, and O2 saturation as required by their care plan. Several entries were missing from the resident's records, which were essential for assessing their condition. An LVN confirmed the absence of these critical measurements, which were necessary to determine if the resident's symptoms were improving or worsening.
A resident in an LTC facility did not receive medications within the prescribed time frame, as required by the facility's policy. The resident's medications, including aspirin, famotidine, and atorvastatin, were frequently administered several hours late, as confirmed by the Medication Administration Audit Report and interviews with the resident and the DON. The facility's policy mandates that medications be given within one hour of the scheduled time, which was not adhered to in this case.
A resident's request for access to medical records was not fulfilled in a timely manner, violating their rights. Despite being alert and oriented, the resident's request to view and send records to a representative was delayed due to a misunderstanding of facility policy and payment requirements. The records were eventually sent after corporate approval, highlighting discrepancies in the facility's handling of such requests.
Failure to Document Meal Intakes for Resident at Nutritional Risk
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement a care plan intervention requiring complete monitoring and documentation of meal intake for a resident at nutritional risk. The resident, who had a history of stroke with hemiplegia and hemiparesis affecting the left non-dominant side, was cognitively intact and required partial/moderate assistance with eating and higher levels of assistance with mobility and toileting. The resident’s care plan, titled “Resident is at nutritional risk” and dated 3/18/2026, identified nutritional risk related to cardiac disease, diet restrictions, and recent hospitalization, with a goal that the resident would consume 75% of at least three meals every day for 90 days. The care plan interventions included monitoring for changes in nutritional status, including changes in intake, ability to feed self, unplanned weight loss/gain, and abnormal labs, and reporting to food and nutrition or the physician as indicated. Record review of the resident’s ADL Meal Log for April 2026 showed missing documentation of meal intake on multiple dates and meals, including no recorded amounts eaten for dinner on 4/1/2026 and 4/2/2026; breakfast, lunch, and dinner on 4/6/2026; breakfast and lunch on 4/8/2026; and dinner on 4/10/2026. During interviews, a CNA confirmed that staff did not document how much the resident ate for those meals and acknowledged that this was not acceptable because the documentation is used to determine how well the resident is eating. An LVN stated that care plan interventions are actions staff implement to solve or reduce problems or complications and that monitoring intake should include documenting intakes for three meals every day; the LVN confirmed the nutritional risk care plan was not followed when staff did not completely document the resident’s meals on the identified dates. The DON reviewed the resident’s progress notes for the same dates and stated that staff did not document reasons why the resident missed a meal or why meal intakes were not fully documented. Facility policies on comprehensive care planning and assisting residents with in-room meals required implementation of measurable objectives and recording how much of the meal was consumed, including reasons and interventions if a meal was refused, which was not done in this case.
Failure to Accurately Assess Fall Risk and Update Fall Interventions After Recurrent Falls
Penalty
Summary
Failure to implement the facility’s Fall Management policy and procedure occurred when staff did not accurately assess and identify a resident as being at risk for falls upon admission and did not develop an appropriate fall risk care plan. The resident, who had a history of stroke with hemiplegia and hemiparesis affecting the left non-dominant side, severe cognitive impairment, and required substantial to total assistance with ADLs and mobility, was documented in the Nursing Documentation Evaluation dated 3/15/2026 as not being at risk for falls. The DON later stated that, based on the resident’s condition at admission (alert but confused, with bilateral lower extremity weakness and a history of stroke), the admitting nurse should have marked disoriented/confused, impaired balance, and predisposing disease or injury under the Fall Risk Factor section, which would have triggered identification of the resident as a fall risk and corresponding safety interventions. After the resident experienced an unwitnessed fall out of bed on 3/17/2026, the care plan interventions included continuing skilled interventions, educating on use of the call light, keeping the bed in the lowest position, and placing a floor mat next to the bed. Following another unwitnessed fall out of bed on 4/4/2026, the care plan entry only added that the call light should be within reach and did not include any new interventions beyond those already in place. During review, LVN 1 confirmed that there was no specific “at risk for fall” care plan for the resident, despite the resident being alert but confused and exhibiting involuntary movements with a history of stroke. At the IDT care conference on 4/6/2026, it was documented that the resident reported attempting to adjust in bed and rolling out, and the IDT recommended a floor mat and low bed position and rehab screening, but the earlier failure to accurately complete the fall risk assessment and to establish a comprehensive fall risk care plan remained the basis of the deficiency.
Failure to Follow Out On Pass Policy and Accompaniment Order
Penalty
Summary
The deficiency involves the facility’s failure to follow its Out On Pass (OOP) policy and a physician’s order for a resident who left the premises without assessment, accompaniment, or signing out. The resident had diagnoses including hemiplegia and hemiparesis, aphasia, and difficulty walking, but was documented as cognitively intact, usually able to understand others, and sometimes able to be understood. The Minimum Data Set showed the resident was independent with eating and rolling in bed, required supervision for bathing, and setup assistance for transfers and wheelchair mobility. A physician’s order dated 1/6/2026 specified that the resident may go out on pass for two to four hours only if accompanied. Progress notes indicated that on 3/31/2026, messages were left for the physician when the resident did not return from being out on pass, and review of the notes for 3/30/2026 showed that no assessment was completed before the resident left. Interviews and record reviews showed multiple failures in the OOP process. The Administrative Assistant at the front desk stated that residents are expected to sign out at the nursing station before going out on pass and that she did not see this resident leave. The DON confirmed that the Resident Out On Pass Log, kept at nursing station 1 near the front door, contained entries for several days but no entry for this resident on 3/30/2026, and stated the resident was aware he needed to sign out and leave with someone. LVN 1 confirmed that no assessment was done before the resident left and acknowledged that the order required the resident to be accompanied. The Activities Assistant reported seeing the resident alone at a bus stop across the street around midday and did not report it because the resident “goes outside a lot.” The facility’s OOP policy required a licensed nurse, prior to the resident leaving, to assess the resident’s physical and mental status and document the time of departure, name of the accompanying responsible person, destination, contact phone number, and expected time of return, which was not done in this case.
Improper Disposal of PPE Outside Resident Room
Penalty
Summary
The facility failed to ensure proper implementation of its infection prevention and control program when a CNA did not discard used personal protective equipment (PPE) in a designated trash bin inside a resident room. During observation in the hallway near a specified room, the CNA was seen exiting the room carrying a used gown and discarding it in a trash bin located across the hallway, rather than disposing of it inside the room. In a subsequent interview, the CNA acknowledged that PPE should have been discarded in the room but stated there was no trash bin available there, and further stated that disposing of PPE inside the room helps prevent the spread of infection and that failure to use a designated bin could increase the risk of cross-contamination and make residents sick. The Infection Prevention Nurse confirmed in an interview that PPE is to be discarded in a designated trash bin inside the room to prevent spread of infection from that room and stated that not using dedicated in-room trash bins could increase the risk of spreading infection to other residents. Review of the facility’s undated PPE policy indicated that training on proper donning, use, and disposal of PPE is provided upon orientation and at regular intervals.
Failure to Complete Admission Inventory of Personal Belongings
Penalty
Summary
The facility failed to protect a resident's personal property by not completing an Inventory of Personal Effects upon admission as required. The resident was admitted with diagnoses including a left artificial knee joint, anxiety disorder, and depression. The California Standard Admission Agreement stated that each resident must identify their personal property inventory in writing on a form provided by the facility. The resident's History and Physical and Minimum Data Set documented that the resident had capacity to understand and make medical decisions, had no cognitive impairment, and no change in mental status, delusions, or hallucinations. Review of the resident's progress notes for the admission month did not indicate that the resident brought in personal belongings at the time of admission. The Inventory of Personal Effects form for the resident, dated several weeks after admission, listed multiple belongings including clothing items, blankets, a wallet/purse, laptop with mouse, phone, seated walker, and wheelchair, but did not show that belongings were inventoried upon admission. During an interview and observation, the resident reported arriving with bags of clothing that went missing during the stay, including a favorite t-shirt, striped shorts, other t-shirts, pants, socks, and a jacket, and stated that staff did not label clothing, provide a personal inventory form, or record belongings at admission. No large plastic bags of clothing were observed in the resident's room or closet. A CNA stated that CNAs and licensed nurses were responsible for documenting residents' personal items on the Inventory of Personal Effects form upon arrival and that all inventory changes must be recorded to avoid items going missing or being stolen.
Failure to Ensure Availability of Prescribed PRN Anti-Anxiety Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a prescribed PRN anti-anxiety medication, alprazolam, was available and could be administered as ordered for one resident. The resident was admitted with diagnoses including a left artificial knee joint, anxiety disorder, and depression, and was documented on the H&P as having capacity to understand and make medical decisions, with the MDS showing no cognitive impairment or change in mental status. Physician orders dated 12/17/2025 prescribed alprazolam 0.5 mg once daily PRN for anxiety manifested by episodes of inability to relax, with instructions for nurses to monitor episodes every shift, document non-drug interventions, and document effectiveness. Review of the MAR showed no alprazolam administration from 12/17/2025 through 12/29/2025, and progress notes did not show that licensed nurses contacted the pharmacy to obtain the medication during that period. The resident reported requesting alprazolam several times between 12/17/2025 and 12/27/2025 and being told by an LVN that the medication was not available; staff offered non-pharmacological interventions that were not always effective, and the resident stated that not having the medication worsened his anxiety and caused frustration and discouragement. The pharmacist stated she received the alprazolam order on 12/19/2025 but could not dispense it because it lacked the required handwritten physician signature, and that facility staff did not contact the pharmacy about the order from 12/20/2025 through 12/28/2025; a signed order was not provided until 12/29/2025, when the medication was sent. The pharmacist and RN confirmed alprazolam was not stocked in the e-kit, so no emergency supply was available. The DON and RN acknowledged that the resident did not have access to alprazolam as ordered from 12/17/2025 through 12/28/2025, that PRN medications should be in stock within two days of admission, and that the facility’s “Administering Medications” policy requiring safe and timely administration as prescribed could not be followed during that time.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident who had recently undergone left hip hemiarthroplasty following a femur fracture. Documentation review showed that the resident required varying levels of assistance with activities of daily living (ADLs), including being dependent for toileting hygiene, requiring maximum assistance for bathing, and moderate assistance for bed mobility and transfers. Despite these needs being documented in the resident's Minimum Data Set (MDS) and other records, the baseline care plan addressing these needs was not created until more than 48 hours after admission, contrary to the facility's policy and procedure. Interviews with facility staff confirmed that the baseline care plan was delayed, and as a result, the care team may not have been fully informed of the resident's specific needs for supervision, behavioral interventions, and assistance with ADLs during the initial period after admission. The Medication Administration Record indicated ongoing monitoring for pain, anticoagulant therapy, and depression, but these interventions were not incorporated into a baseline care plan within the required timeframe. The lack of a timely baseline care plan was acknowledged by nursing staff, who stated that this could have resulted in the resident's needs not being met appropriately.
Failure to Monitor and Assess Post-Surgical Wound Leading to Infection and Dehiscence
Penalty
Summary
The facility failed to provide care in accordance with professional standards and the resident's person-centered care plan for a resident admitted with a left hip surgical incision following hemiarthroplasty. Upon admission, the resident's care plan required monitoring for signs of infection and skin breakdown at the surgical site, but documentation and interviews revealed that staff did not consistently assess or document the condition of the wound. The Treatment Administration Record (TAR) lacked evidence of daily monitoring for infection, and weekly wound measurements and assessments were not performed as required by facility policy. Additionally, the baseline care plan was not developed in a timely manner, and interventions for monitoring infection were not implemented or documented. The resident experienced multiple episodes of significant pain at the surgical site, which were recorded in the Medication Administration Record (MAR), but the location, quality, and aggravating factors of the pain were not assessed or documented by licensed nurses. Despite repeated reports of pain, there was no indication that the surgical wound was evaluated for changes in condition or signs of infection during these episodes. Both the physician and physician assistant did not assess the wound directly, relying instead on nursing staff, who only observed the dressing and not the underlying incision. This lack of direct assessment contributed to a failure to identify early signs of infection or wound complications. The resident's follow-up appointment with the surgeon was not scheduled in a timely manner as ordered, and the wound was not evaluated by a wound care specialist until after dehiscence occurred. When the resident eventually developed wound dehiscence with drainage and increased pain, the issue was not promptly addressed by staff, leading the resident to call emergency services independently. Subsequent hospital evaluation confirmed infection and required surgical intervention. Interviews with staff and review of facility policies confirmed that required assessments, documentation, and communication regarding the resident's wound status were not performed as outlined in the care plan and facility protocols.
Failure to Implement Physician's Orders for Pain Management
Penalty
Summary
The facility failed to implement the physician's orders for pain management for one resident following a left hip hemiarthroplasty. The resident had a history of left femur fracture, generalized anxiety disorder, and polyneuropathy, and was admitted for aftercare following joint replacement surgery. Physician orders required staff to document non-pharmacological interventions for pain, such as heat, repositioning, relaxation breathing, food/fluid, massage, exercise, and immobilization, and to document the results. The orders also specified that Tramadol 50 mg could be administered every six hours as needed for moderate to severe pain rated 5 to 10 out of 10. The resident's care plan and physician orders further required pain monitoring every shift and documentation of non-pharmacological interventions and their results. Record review revealed that the resident experienced moderate pain on several occasions, but there was no documentation that non-pharmacological interventions were offered or provided as required by the physician's orders. Additionally, the Medication Administration Record (MAR) showed that the resident received Tramadol on multiple occasions when reporting 0/10 pain, which did not meet the prescribed parameters. Interviews with nursing staff confirmed that non-pharmacological interventions were not consistently offered or documented, and that pain medication was administered outside of the physician's order parameters. Further interviews with the resident and medical staff corroborated that non-pharmacological pain management interventions were not offered when the resident reported pain and discomfort. The facility's policies required documentation of non-pharmacological interventions and administration of medications in accordance with prescriber orders, but these were not followed. The deficiency was identified through review of records, interviews with staff and the resident, and examination of facility policies.
Failure to Provide Menu-Specified Protein Item to Residents
Penalty
Summary
The facility failed to provide the pork sausage patty as indicated on the menu and meal tickets for two residents during breakfast service. Both residents had meal tickets and dietary profiles that specified a regular diet with no restrictions or dislikes for pork or sausage, and both were assessed as needing adequate protein and calorie intake due to their medical conditions. Observations confirmed that the breakfast trays delivered to these residents did not include the sausage patty, despite it being listed on their meal tickets and the facility's approved menu. For the first resident, documentation showed diagnoses including generalized muscle weakness, anemia, and chronic kidney disease, with a care goal to maintain optimal oral intake and avoid significant weight change. The resident was cognitively intact and had no dietary restrictions. During the breakfast meal observation, the resident expressed disappointment at not receiving the sausage patty. The Dietary District Manager (DDM) and Registered Dietitian (RD) confirmed that the resident should have received the sausage patty as per the menu and meal ticket, and that staff are responsible for ensuring trays match the meal tickets before delivery. The second resident had diagnoses of muscle weakness, respiratory failure, and COPD, with a care plan to improve nutritional status and tolerate a high-protein diet. The resident's nutrition assessment indicated moderate protein-calorie malnutrition and a goal to gain weight. The breakfast tray delivered did not contain the sausage patty, and the resident expressed feeling disheartened. Staff interviews revealed that the sausage patty was not included as required, and the DDM and RD confirmed this was not in accordance with the resident's dietary order. The failure to provide the specified menu item was observed and acknowledged by dietary and nursing staff.
Failure to Honor Resident Food Preferences During Meal Service
Penalty
Summary
The facility failed to ensure that a resident's food preferences were honored during meal service. Despite documentation in the resident's Dietary Profile and Meal Ticket indicating dislikes for orange juice and hot cereal, these items were included on the resident's breakfast tray. The resident, who was cognitively intact and able to express her preferences, reported the issue to a CNA, who removed the orange juice but left the hot cereal. The Dietary Services Supervisor later confirmed that the tray still contained hot cereal, which was on the resident's dislike list. A review of the facility's policy and procedure on Dining and Food Preferences indicated that residents who refuse certain foods should be offered alternative selections of comparable nutritive value. The Registered Dietitian confirmed that the policy was not followed in this instance, as the resident received food items she had specifically indicated she disliked. This failure resulted in the resident feeling angry and distressed, and constituted a violation of her rights.
Inaccurate Documentation of Surgical Site and Wound Assessment
Penalty
Summary
The facility failed to maintain accurate and consistent documentation for a resident who had undergone left hip hemiarthroplasty. Record reviews revealed discrepancies in the resident's medical records, including conflicting information about the location of the surgical site, the presence of hematuria, and the timing and identification of wound dehiscence. For example, the Inter-Facility Transfer Report and admission records indicated a left hip surgical site, but a Daily Body Check incorrectly documented treatment on the right hip. Additionally, a nurse misinterpreted 'hematuria' as bloody discharge from the surgical site, when it actually refers to blood in the urine, leading to inaccurate wound assessment documentation. Further inconsistencies were found in the documentation of the resident's change of condition, with the timing of wound dehiscence being incorrectly recorded as occurring in the morning instead of the afternoon. Interviews with the Treatment Nurse and Director of Nursing confirmed these documentation errors. The facility's policy requires nursing documentation to be accurate and based on the resident's condition, but these standards were not met in this case.
Failure to Provide Timely Incontinent Care Resulting in Resident Left in Soiled Linens
Penalty
Summary
A resident was observed lying in bed with a diaper and bed linen soaked with urine, and was seen scratching her buttocks area while wearing a hand mitten. The Certified Nurse Assistant (CNA) present stated that he had not provided the resident with morning care or a diaper change. The resident's Minimum Data Set (MDS) indicated she was dependent on staff for toileting and personal hygiene and was incontinent of both bowel and bladder. The care plan for the resident specified that staff were to assist with perineal care as needed to maintain dignity, comfort, and prevent complications related to incontinence. During the interview, the CNA admitted to checking on the resident at the start of his shift but did not check her diaper. He acknowledged that failure to provide timely incontinent care could result in skin redness, irritation, and wounds. The facility's policy on perineal care emphasized the importance of cleanliness and comfort to prevent infections and skin irritation. The failure to provide timely incontinent care as outlined in the care plan and facility policy led to the resident remaining in soiled linens and a wet diaper.
Failure to Post Current Nurse Staffing Information Daily
Penalty
Summary
The facility failed to ensure that the Direct Care Service Hours Per Patient Day (DHPPD) information, which includes the updated census and number of staff on duty, was posted daily as required. During an observation and interview at Nursing Station 1, the DHPPD posted was found to be three days old, and the Director of Staff Development acknowledged that the information was not current and should be updated daily. The facility's policy and procedure requires that nurse staffing data for each shift, including the number of licensed and unlicensed nursing personnel responsible for direct care, be posted in a prominent and accessible location within two hours of the beginning of each shift. This deficiency was identified through observation, interview, and review of facility policy.
Improper Labeling and Storage of Medications and Supplements
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals for two residents. For one resident, multivitamin supplements were stored in the medication cart with only the room number as an identifier, lacking the resident's name and date of birth. Both a registered nurse and a licensed vocational nurse confirmed that supplements and medications should be labeled with the resident's name and date of birth, as per facility practice, to prevent potential mix-ups if a resident is moved to another room. For another resident, a box containing morphine sulfate solution was found in the medication cart with a medication label belonging to a different, previously discharged resident. A licensed vocational nurse acknowledged that this labeling error could lead to medication errors. The facility's policy requires that all medications, including nonprescription items, be labeled with the resident's name and that containers with confusing or incorrect labels be returned to the pharmacy or destroyed.
Failure to Update Physician Orders and Complete Admission Skin Assessment
Penalty
Summary
The facility failed to ensure that physician orders were updated for a resident when licensed staff received a telephone order regarding medication administration. Specifically, the physician orders for a resident with a g-tube and swallowing difficulties did not reflect a new order allowing medications to be given by mouth. Despite a physician communicating via text that oral administration was permitted, this change was not transcribed into the resident's official orders. Both a Licensed Vocational Nurse and a Registered Nurse confirmed that the order to administer medications orally was missing from the resident's record, and acknowledged the importance of updating orders to ensure safe medication administration. Additionally, the facility did not complete an initial body check for another resident upon admission, resulting in incomplete documentation of the resident's skin status. The resident, who had multiple diagnoses including muscle weakness, diabetes, and chronic kidney disease, was at risk for pressure ulcers and had a documented deep tissue injury. The required skin assessment was not performed or documented on the day of admission, as confirmed by a Registered Nurse during record review and interview. Facility policies reviewed indicated that nursing documentation should be clear, accurate, and timely, and that newly admitted residents should have their skin examined for existing conditions. In both cases, the lack of timely and complete documentation led to incomplete medical records for the residents involved.
Improper Disposal of PPE Gown Outside Resident Room
Penalty
Summary
A Licensed Vocational Nurse (LVN) was observed exiting the room of two residents while still wearing a used PPE gown, which was then removed and discarded in a linen hamper located in the hallway outside the residents' room. According to interviews with the LVN, the Infection Prevention Nurse (IPN), and the Interim Director of Nursing (IDON), the proper procedure is to remove and dispose of used PPE inside the resident's room to prevent cross contamination and the spread of infections. The facility's policy and procedure on PPE gowns, revised in December 2023, also specifies that soiled gowns must be removed and discarded in appropriate receptacles located in the room or work area before leaving. This incident demonstrates a failure to follow established infection prevention and control protocols, as staff did not dispose of used PPE in the designated area within the resident's room. The deviation from policy was confirmed through direct observation, staff interviews, and review of facility procedures, all of which indicated that disposing of PPE in the hallway constitutes a break in infection control practices.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that 23 out of 36 resident rooms met the required minimum of 80 square feet per resident in multiple occupancy rooms. During a facility tour and observation, it was noted that residents in these rooms were able to move in and out and had space for their personal property. However, a review of the facility's Client Accommodations Analysis form, completed by the Maintenance Director, confirmed that these rooms did not meet the space requirement. The Administrator acknowledged that the rooms were out of compliance with the square footage standard, although stated that resident care was not affected. Documentation reviewed included a waiver request letter submitted by the administrator, which listed the specific rooms and their square footage, confirming the deficiency.
Failure to Provide Menu Access and Food Choices to Bed or Chair Bound Residents
Penalty
Summary
The facility failed to ensure that all residents, including those who are bed or chair bound, had access to the weekly menu and list of alternative meal choices. Menus were posted only outside the kitchen, making them inaccessible to residents with physical limitations. Two residents with decision-making capacity and varying levels of assistance required for eating reported not being aware of the menu or alternative choices, and stated they had not been offered food options since admission. Both residents indicated they would have liked to know about or choose different food items, but instead ate what was served to them without being informed of alternatives. Interviews with staff confirmed that menus were only available on the wall outside the kitchen, and that Certified Nursing Assistants could bring menus to residents if requested. However, this process relied on residents knowing to ask, which did not occur for the affected individuals. Facility policies indicated that residents have the right to communication and access to services, and that menus should reflect resident choices, but these were not followed in practice for residents with physical limitations.
Call Light Not Accessible to Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as observed during a survey. The resident in question had diagnoses including dementia, schizoaffective disorder, and gastro-esophageal reflux disease, and was assessed as having severe cognitive impairment with a need for substantial to maximal assistance for activities such as showering, toileting hygiene, and dressing. During an observation, the call light was found hanging behind the resident's bed and not accessible to the resident. Interviews with both a Licensed Vocational Nurse and a Certified Nursing Assistant confirmed that the call light was not within reach and acknowledged the importance of accessibility for the resident to communicate needs. The facility's policy and procedures require that call lights be accessible to residents when in bed, but this was not followed in this instance, resulting in the deficiency.
Failure to Revise Care Plan After Change in Medication Administration Route
Penalty
Summary
The facility failed to revise the care plan for a resident with a history of dysphagia, GERD, and a g-tube, after the physician authorized a change in medication administration from g-tube to oral route. The resident's care plan continued to reference interventions for swallowing food and drinks, such as maintaining an upright position and encouraging small sips or bites, but did not address the new order for oral medication administration. Additionally, the care plan for dysphagia only included speech therapy interventions and did not specify what actions staff should take when administering medications by mouth, despite the resident's ongoing risk for swallowing difficulties. Interviews with the medical doctor and registered nurse confirmed that the care plan was not updated to reflect the change in medication administration, which could lead to confusion among staff. The facility's policy required comprehensive care plans to be developed and revised based on identified problem areas and changes in resident status, but there was no specific policy for revising care plans when triggers or changes occurred. The deficiency was identified through record review and staff interviews, and it was noted that the lack of care plan revision had the potential for repeat occurrences.
Failure to Follow Physician's Order for Blood Pressure Medication
Penalty
Summary
The facility failed to follow a physician's order regarding the administration of losartan for a resident with a history of syncope and hypertension. The physician's order specified that losartan should be held if the resident's systolic blood pressure (SBP) was less than 110 mmHg. Despite this, documentation showed that the resident received losartan on two occasions when her SBP was recorded as 105 mmHg and 100 mmHg, both below the threshold set by the physician. A review of the resident's records confirmed that the medication was administered contrary to the order, and this was acknowledged by the Licensed Vocational Nurse (LVN) involved, who stated that the medication should not have been given under those circumstances. The facility's policy on medication administration requires that medications be given in accordance with physician orders, which was not followed in this instance.
Failure to Assist Resident Out of Bed for Meals as Ordered
Penalty
Summary
The facility failed to ensure that a resident was taken out of bed during mealtimes as ordered by the physician. The resident, who had diagnoses including epilepsy, cerebral infarction, dysarthria, and diabetes mellitus, was dependent on staff for all activities of daily living and had limited range of motion in both upper and lower extremities. Despite a physician order specifying that the resident should be taken out of bed daily during mealtimes, observations over several days showed the resident remained in bed while eating. The care plan did not include the intervention to remove the resident from bed during meals, and staff interviews revealed a lack of awareness of the physician's order. The resident expressed a desire to be taken out of bed to eat if staff would assist, and staff acknowledged the importance of this intervention for the resident's mobility and well-being. The facility's policy required care and services to maintain or improve residents' ability to carry out activities of daily living, including mobility and dining. However, the failure to follow the physician's order and update the care plan resulted in the resident not being provided the opportunity to eat out of bed, potentially impacting her functional abilities.
Physician Review of Pharmacist Medication Recommendations Not Documented
Penalty
Summary
The facility failed to ensure that a physician reviewed and acted upon a pharmacist's recommendation following a monthly Medication Regimen Review (MRR) for a resident with atrial fibrillation and heart failure. The resident was prescribed amiodarone and carvedilol, both of which can affect heart rate, and the pharmacist recommended monitoring for signs of bradycardia due to the combined effects of these medications. However, there was no documentation indicating that the physician had reviewed or responded to the pharmacist's recommendation for the month of May. Interviews and record reviews revealed that the MRR was typically kept in the DON's office, and staff would inform the physician of any recommendations if requested. In this instance, the responsible RN was not asked to review the MRR, and the DON had resigned, resulting in a lack of follow-up. Facility policy required that recommendations from the pharmacist be acted upon and documented by staff or the prescriber, with the physician expected to accept, act upon, or reject the suggestion by the next visit. This process was not followed for the resident in question.
Failure to Administer Clonidine as Ordered for Hypertensive Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering clonidine as ordered for high blood pressure. The medication order specified that clonidine 0.1 mg should be given by mouth every six hours as needed for systolic blood pressure greater than 150. Review of the Medication Administration Records (MAR) for March, April, May, and June showed that although blood pressure was checked every six hours as ordered, there were 33 instances where clonidine was not administered when indicated, as evidenced by blank spaces on the MAR where nurse initials should have been recorded after administration. The resident involved had a history of hypertension, cardiac arrhythmia, and hyperkalemia, and required substantial to maximal assistance with activities of daily living. Interviews with the resident revealed that he was not aware of whether clonidine was given and relied on nursing staff for medication administration. An LVN confirmed that the medication was not given as ordered and acknowledged the potential for serious consequences. Facility policy required medications to be administered according to physician orders and for the MAR to be properly documented, which was not followed in this case.
Failure to Prevent Mental Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from mental abuse and did not follow its own Abuse Prohibition Policy and Procedure. One resident, who had diagnoses including schizoaffective disorder, major depressive disorder, and anxiety disorder, reported being subjected to repeated verbal outbursts and threatening behavior from a roommate with a history of psychiatric and mood disorders, including bipolar disorder and PTSD. The roommate exhibited aggressive and verbally abusive behavior, including yelling, using profanity, and, on one occasion, placing a hand on the resident's shoulder and picking up a butter knife in a threatening manner. These actions caused the resident to feel uncomfortable and unsafe. Staff interviews and record reviews revealed that the roommate had a documented history of behavioral issues, including agitation and verbal abuse toward others. The care plan for the roommate included monitoring for aggression and agitation, and the resident was placed on one-to-one supervision to prevent further incidents. However, on the day of the incident involving the butter knife, the assigned CNA stepped away from the room, leaving the roommate unsupervised. This lapse in supervision allowed the altercation to occur, during which the resident was threatened and felt intimidated. The facility's Abuse Prohibition Policy and Procedure explicitly prohibits mental abuse, including threats and conduct that can cause intimidation or fear. Staff acknowledged that the actions of the roommate constituted mental abuse according to the policy and that the lack of supervision contributed to the incident. The failure to maintain required supervision and prevent abusive behavior resulted in the resident experiencing mental abuse and feeling unsafe in their environment.
Failure to Report Fracture of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report a femur fracture of unknown origin for a resident to the California Department of Public Health (CDPH), resulting in a delay of investigation by the state agency. The resident, who had diagnoses including osteoarthritis of the hip, end stage renal disease, and was on dialysis, was found to have a right femur fracture after complaining of increased pain in her lower back, hips, and right leg. The x-ray confirmed the fracture, and both the family and physician were notified. The resident was cognitively intact and denied any fall, rough handling, or abuse, stating she did not know how the fracture occurred. Nursing staff, upon receiving the x-ray results, questioned the resident about possible causes, all of which she denied. The Director of Nursing and the Administrator were informed of the situation. The Administrator interviewed the resident, who again denied any incident or abuse, and the Administrator relied on the physician's assessment that the fracture was pathological due to the resident's long-term dialysis and underlying medical conditions. Based on this information, the Administrator determined that the incident did not meet the criteria for reporting as an unusual occurrence or injury of unknown origin. A review of the facility's policy indicated that all unusual occurrences are to be reported to the appropriate state agency within 24 hours. Despite this, the incident was not reported to CDPH, as the facility leadership believed the cause of the fracture was known and not suspicious. This decision was made even though the origin of the fracture was not clearly identified by the resident or staff, and the event was not reported as required by policy.
Failure to Follow Safety Protocols During Resident Care on Low Air Loss Mattress
Penalty
Summary
Certified nurse assistant (CNA) 5 failed to follow established safety protocols while providing care to a resident who was dependent on staff for all mobility and had moderately impaired cognition. The resident, who had muscle weakness and encephalopathy, was ordered to use a low air loss mattress (LALM) for skin management. During a routine care activity, CNA 5 changed the resident on the LALM without placing the mattress in static mode and without the required two-person assistance. As a result, the resident rolled off the bed and fell to the floor. Interviews and record reviews confirmed that facility policy and in-service training required the LALM to be set to static mode and a two-person assist to be used when changing immobile residents on this type of mattress. CNA 5 admitted to not being aware of these requirements at the time of the incident. The incident was corroborated by progress notes and staff interviews, which highlighted the deviation from established procedures intended to prevent such accidents.
Failure to Timely Document Medication Administration
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to document the administration of seven scheduled medications for a resident with a history of cerebral infarction, hemiplegia, and diabetes. The resident, who was moderately cognitively impaired and dependent on staff for daily activities, had medications scheduled for 9:00 a.m. that were not documented as given in the Medication Administration Record (MAR). During an interview and record review, the LVN confirmed that the medications were administered but not documented due to being busy, and acknowledged that documentation should occur at the time of administration. The facility's policy and procedure for administering medications requires the individual administering the medication to initial the MAR after giving each medication and before administering the next. The lack of timely documentation resulted in no indication that the resident received the medications, as evidenced by the MAR showing the medications in red, which signifies they were late or not given. This failure to document as required constituted the identified deficiency.
Missed Timely Administration of Insulin Dose
Penalty
Summary
A resident with a history of cerebral infarction, hemiplegia, and diabetes was admitted and readmitted to the facility, requiring insulin for diabetes management. The resident's care plan specified insulin dependence and directed staff to administer hypoglycemic medications as ordered. The resident was assessed as having moderately impaired cognition and was dependent on staff for daily activities. On review of the Medication Administration Record (MAR), it was found that the resident's scheduled dose of Lispro, a fast-acting insulin, was not administered at the prescribed time. During an interview and record review, an LVN confirmed that the Lispro dose, scheduled for 1:00 p.m., was not given because the nurse was busy. The MAR indicated the missed dose by displaying it in red, which the LVN explained signified a late or omitted medication. Facility policy required medications to be administered within one hour of the scheduled time, but this was not followed. The LVN acknowledged that this constituted a medication error and that timely administration was necessary according to the prescriber's order.
Failure to Address and Manage Resident Pain Related to Indwelling Catheter
Penalty
Summary
The facility failed to provide necessary care and services to relieve pain for a resident with obstructive and reflux uropathy and an indwelling catheter. The resident was admitted with diagnoses including obstructive and reflux uropathy and difficulty walking, and was assessed as able to understand and communicate needs. Orders were in place for acetaminophen as needed for moderate to severe pain, but there was no order to monitor pain levels. The resident's medication administration record showed that pain medication was not administered on several days when the resident reported pain. Multiple observations and interviews revealed that the resident experienced significant penile pain related to the Foley catheter, which was not properly secured, causing pulling and discomfort. The resident reported pain to CNAs and LVNs over several days, but no action was taken to address the pain or administer pain medication. Family members also observed the resident's discomfort and reported that the pain was affecting the resident's ability to participate in physical therapy and daily activities. Staff interviews confirmed that the pain was reported but not addressed, and the resident's pain was only acknowledged and treated after several days of complaints. Physical therapy notes indicated the resident declined therapy sessions due to pain, and staff confirmed that the pain and refusal to participate were reported to nursing staff. The DON acknowledged that the resident's pain was not addressed as required, and the MAR confirmed a lack of pain medication administration during the period of reported pain. The facility's policy required care that promotes resident well-being and dignity, but this was not followed in the resident's case.
Delay in Suprapubic Catheter Care Resulting in Resident Discomfort
Penalty
Summary
The facility failed to provide timely care and services for a resident with a suprapubic catheter, as required by physician orders and the resident's care plan. The resident, who had quadriplegia and neurogenic bladder, was dependent on staff for all activities of daily living and required her suprapubic catheter to be lavaged with 200 cc every Monday, Wednesday, and Friday during the day shift. On the day in question, the resident began requesting the catheter flush at 10:00 a.m., but the procedure was not performed by 3:20 p.m. despite multiple requests. The resident reported increasing abdominal spasms and discomfort due to the delay. Staff interviews revealed that the treatment nurse was absent, and coverage was uncertain. The registered nurse acknowledged being too busy with other admissions and discharges to perform the catheter flush as scheduled. The facility's policy required that residents receive care and services to maintain or improve their ability to carry out activities of daily living, but this was not followed in this instance, resulting in the resident experiencing discomfort and bladder spasms.
Failure to Assess and Manage Pain Related to Indwelling Catheter
Penalty
Summary
A deficiency occurred when staff failed to thoroughly assess and manage a resident's pain associated with an indwelling Foley catheter. The resident, who had diagnoses including obstructive and reflux uropathy and difficulty walking, was admitted with an order for acetaminophen as needed for moderate to severe pain. Despite repeated complaints of penile pain related to the catheter, there was no evidence that pain assessments were conducted or that pain medication was administered during several days when the resident reported discomfort. Physical therapy notes documented the resident's refusal to participate in therapy due to increased penile pain from the catheter, and family members also reported the resident's ongoing pain to staff. Observations revealed that the catheter was not secured properly, causing pulling and pain, and redness and white spots were noted at the insertion site. Staff interviews confirmed that the resident's pain was reported to nurses, but there was no documentation of follow-up, pain assessment, or consistent administration of pain medication. The facility's pain management policy required identification, assessment, treatment, and evaluation of pain to maintain resident comfort. However, the lack of timely assessment and intervention for the resident's pain resulted in unaddressed discomfort, refusal of therapy, and delayed recovery. The failure to secure the catheter and respond to pain complaints was directly observed and confirmed by multiple staff and family interviews.
Failure to Ensure Staff Competency in Securing Foley Catheter
Penalty
Summary
Nursing staff failed to demonstrate competency in securing a Foley catheter (FC) for a resident with obstructive and reflux uropathy, resulting in prolonged pain and discomfort. The resident, who was admitted with significant urinary tract issues and required an indwelling catheter, repeatedly reported pain at the catheter insertion site to both CNAs and LVNs over several days. Family members observed that the catheter was pulling and likely causing the pain, and staff confirmed the resident had been complaining of pain whenever the FC was touched or moved. Upon observation, redness and white spots were noted at the insertion site, and the FC was found unsecured. When attempts were made to secure the FC using a device, the assigned RN was unable to do so, admitting a lack of knowledge on how to use the securing device. The Director of Nursing later clarified that the facility did not use the specific securing device present and that staff should have replaced it with the device they were trained to use. The failure to secure the FC appropriately led to ongoing pain and irritation for the resident, as documented in interviews, observations, and record reviews.
Failure to Report Change in Resident Behavior
Penalty
Summary
The facility failed to report a change in behavior for one of three sampled residents. A certified nursing assistant (CNA) observed that the resident appeared more confused than usual and initiated a Stop & Watch notification, which is intended to alert staff to significant changes in a resident's condition. However, the CNA did not inform the charge nurse of these observed changes, and there was no documentation of a Stop & Watch notification in the resident's medical record or on the facility's dashboard. The Social Services Director was also not informed of any behavioral changes, and as a result, no referral to a psychologist or psychiatrist was made. The resident in question had a history of depression and anxiety disorder and was hospitalized for a urinary tract infection (UTI) following the observed change in behavior. The care plan for this resident included monitoring for changes in cognitive status and notifying the physician as needed. Despite these interventions being in place, the required notifications to the physician, resident, and resident representative were not made when the change in behavior occurred, as outlined in the facility's policy and procedures.
Failure to Ensure Nursing Staff Competency in Medication Administration and Monitoring
Penalty
Summary
Licensed nursing staff failed to demonstrate the necessary competencies and skills to safely administer medications as ordered for two residents. In one instance, an LVN did not check a resident's blood pressure in the supine position as required before administering Droxidopa, a medication prescribed for orthostatic hypotension. Instead, the LVN measured the blood pressure while the resident was upright, despite the physician's order and a black box warning specifying the need for a supine reading. The Director of Nursing confirmed that the correct procedure was not followed, which could have resulted in an inaccurate assessment prior to medication administration. In another case, a resident with orders for insulin administration based on blood sugar levels did not have their blood sugar checked or documented at two specified times. The Medication Administration Record did not show evidence of blood sugar checks on the dates and times required by the physician's order. The DON acknowledged the absence of documentation and emphasized the importance of proper blood sugar monitoring and documentation for residents receiving insulin. Both incidents were identified through observation, interview, and record review. The facility's policy requires all nursing staff to meet specific competency requirements based on resident needs, as determined by assessments and care plans. The failures in these cases demonstrate that the nursing staff did not meet the required competencies for medication administration and monitoring as outlined in facility policy and physician orders.
Failure to Perform Hand Hygiene After Glove Removal
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to perform hand hygiene after removing gloves and before donning a new pair of gloves while providing care to a resident. The LVN was observed administering medications to a resident, removing her gloves, and then immediately putting on a new pair of gloves without washing her hands or using an alcohol-based hand sanitizer. This action occurred at the resident's bedside and was directly observed by surveyors. The resident involved had multiple medical conditions, including orthostatic hypotension, a gastrostomy tube, diastolic heart failure, and Parkinsonism, and was totally dependent on staff for activities of daily living. The facility's policy required staff to perform hand hygiene after removing personal protective equipment (PPE) and before resident contact, but this protocol was not followed. Both the LVN and the Director of Nursing acknowledged during interviews that hand hygiene should have been performed to prevent the spread of infection.
Failure to Implement Emergency CPR Procedures and AED Use for Full Code Resident
Penalty
Summary
Facility staff failed to implement their policy and procedure for emergency response and cardiopulmonary resuscitation (CPR) for a resident with a full code status who was found unresponsive in bed. A Certified Nursing Assistant (CNA) observed the resident was not breathing but left the resident unattended to notify Registered Nurses (RNs) instead of activating the code blue system or initiating immediate life-saving measures. The CNA did not check the resident's vital signs or pulse upon finding the resident unresponsive and did not activate the code blue as required by facility policy. When the RNs and a Licensed Vocational Nurse (LVN) responded, they initiated CPR but did not utilize the facility's Automated External Defibrillator (AED), despite the policy requiring staff to be trained in its use. One RN admitted to not knowing how to use the AED and confirmed that staff had not been trained on its use during CPR. The staff also failed to check and document the resident's vital signs and blood sugar during the code, even though the resident had a history of diabetes and other significant medical conditions. The facility's policy required all clinical staff to be trained and certified in Basic Life Support (BLS)/CPR, including the use of defibrillation, and to follow a specific sequence of actions during a code blue. However, interviews and record reviews revealed that staff were not knowledgeable or adequately trained in these emergency procedures, resulting in the failure to provide timely and appropriate life-saving interventions for the resident. This deficiency was identified as having resulted in the resident's death and placed other residents with full code status at risk.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for three of nine sampled residents, as observed during multiple room visits. In one instance, a resident with hemiplegia, blindness in one eye, and epilepsy was found unable to reach the call light, which was tangled on the bed's siderail. The resident expressed the need for the call light to be accessible to request assistance, such as for water. A CNA confirmed the call light should be within reach and corrected the placement during the observation. Another resident, who was asleep and had diagnoses including cerebral ischemia and muscle weakness, was found with the call light hanging outside the bed and not accessible. The CNA placed the call light in the resident's hand upon noticing this. Both residents were dependent on staff for activities of daily living, transfers, and bed mobility, with one having cognitive impairment. A third resident, also dependent for ADLs and with cognitive impairment, was observed with the call light placed on top of the nightstand, out of reach. An LVN acknowledged that the call light should have been closer to the resident. Staff interviews confirmed that all facility staff are responsible for ensuring call lights are accessible and for responding to them promptly. Review of facility policy indicated that call lights must be accessible to residents when in bed, on the toilet, or during bathing.
Failure to Monitor Diabetic Resident for Hypo/Hyperglycemia Symptoms
Penalty
Summary
The facility failed to monitor a resident with a history of diabetes mellitus, including diabetic ketoacidosis and hyperglycemia, for signs and symptoms of hypoglycemia and hyperglycemia, despite physician orders and care plan interventions. The resident had documented refusals of blood sugar checks and insulin, and the care plan specifically directed staff to monitor for symptoms of blood sugar abnormalities. However, there was no documentation in the progress notes or other records indicating that staff monitored the resident for these symptoms, even when blood sugar checks were refused. Physician orders required blood sugar monitoring before meals and at bedtime, with insulin administration per sliding scale, and included protocols for managing hypoglycemia. Despite these orders, the resident's blood sugar was not checked at required times, and there was no evidence of staff monitoring for clinical signs of hypo- or hyperglycemia. The resident was later found in cardiac arrest with a critically high blood sugar level, and staff interviews confirmed the lack of monitoring and documentation for symptoms related to blood sugar abnormalities.
Failure to Follow Physician's Wound Care Orders and Document Treatment
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for wound care and did not document the treatment provided to a resident with hemiplegia, hemiparesis, obstructive and reflux uropathy, and chronic kidney disease. The physician's order specified that urea cream 40% should be applied to both lower extremities after a shower or bed bath, and the legs should be wrapped with kerlix every dayshift for 30 days. Observations and interviews revealed that the treatment nurse did not consistently apply the lotion or wrap the resident's legs as ordered. On multiple occasions, the resident's lower legs were not wrapped, and the resident reported that the treatment was not performed daily as prescribed. Review of the Treatment Administration Record (TAR) for several consecutive days showed no documentation of the wound care treatment. The LVN responsible for the care confirmed that she did not document the treatments on those days and acknowledged that if the treatment was not documented, it was not done. The Director of Nursing also confirmed the importance of following physician orders and documenting wound care in the TAR, as required by facility policy. The facility's policy stated that the name and title of the individual performing wound care should be documented in the clinical record.
Failure to Ensure Proper Catheter Care and UTI Prevention
Penalty
Summary
A deficiency was identified when a resident with a suprapubic Foley catheter was observed to have cloudy, amber-colored urine with visible sediments in the drainage bag. During the observation, a Licensed Vocational Nurse (LVN) acknowledged the presence of these signs and stated that the catheter needed to be irrigated. The resident's medical record indicated diagnoses including hemiplegia, obstructive and reflux uropathy, and chronic kidney disease. The resident was noted to have no cognitive impairment and required substantial assistance with activities of daily living. A physician's order was in place to irrigate the Foley catheter with 30ml as needed for maintenance. Further interviews revealed that facility protocol required daily assessment of the Foley catheter, and that any observation of amber urine, sediments, or cloudiness should prompt a change of condition report, physician notification, and urine specimen collection. The Director of Nursing confirmed that Foley catheters must be assessed every shift and that the physician should be notified if sediments are observed. The failure to follow these procedures resulted in the resident not being free from signs of urinary tract infection, as evidenced by the observed condition of the urine and drainage bag.
Medication Administration Delays Due to Insufficient Staffing
Penalty
Summary
The facility failed to ensure that Licensed Vocational Nurses (LVNs) were able to administer medications timely as ordered by physicians for two of the five sampled residents. Resident 1, who was admitted with diagnoses including metabolic encephalopathy and chronic obstructive pulmonary disease, reported not receiving her pain medication on time and had to personally request it at the nurses' station. Similarly, Resident 2, with diagnoses including hypertension and atrial fibrillation, experienced delays in receiving scheduled medications, with records showing significant delays on multiple occasions. Interviews with LVNs revealed that they were responsible for a high number of residents, which made it challenging to administer medications on time. LVNs reported interruptions during medication passes, such as responding to call lights and assisting residents, which contributed to the delays. The Director of Nursing stated that staff had not complained about the workload, and overtime was allowed with management approval. The facility's policy indicated that sufficient nursing staff should be provided to meet residents' needs, but the current staffing levels were inadequate to ensure timely medication administration.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide medications to four out of five sampled residents in a timely manner and as ordered by the physician. Observations and interviews revealed that medications scheduled for 9:00 a.m. were administered several hours late to Residents 2, 3, 4, and 5. Licensed Vocational Nurse (LVN 1) and LVN 4 both reported difficulties in administering medications on time due to the high number of residents they were responsible for and frequent interruptions during medication passes. The Registered Nurse Supervisor confirmed that the medications were not administered as scheduled, which is against the facility's policy that requires medications to be given within one hour before or after the scheduled time. Additionally, the facility failed to ensure that medications were administered correctly to Resident 2. LVN 1 was observed crushing three medications, including an extended-release medication, and mixing them with applesauce before administering them to Resident 2. This practice was not supported by a physician's order and had the potential to alter the medication's intended release mechanism, potentially affecting its therapeutic efficacy. The facility's pharmacy consultant confirmed that the extended-release medication should not be crushed, as it could lead to immediate release and increased frequency of urination for Resident 2. The facility's policy and procedure on medication administration emphasize that medications should be administered as prescribed by the physician and that long-acting or enteric-coated dosage forms should not be crushed. The policy also states that the facility should have sufficient staff to allow for the administration of medication without unnecessary interruptions. However, the report indicates that staffing issues and interruptions during medication passes contributed to the deficiencies observed in the administration of medications to the residents.
Improper Medication Administration Due to Crushing Without Order
Penalty
Summary
The facility failed to ensure that medications for one of the residents were administered as ordered by the physician. Specifically, the staff crushed three medications together, including an extended-release medication, without a physician's order. This practice was observed during a medication administration session where a Licensed Vocational Nurse (LVN) crushed the medications and mixed them with apple sauce before administering them to the resident. The resident had been admitted with diagnoses including hypertension, atrial fibrillation, and anxiety disorder, and had the ability to make her needs known. The resident stated she preferred her medications crushed for easier swallowing, and the LVN confirmed this practice was followed without obtaining the necessary physician's order. The facility's pharmacy consultant later confirmed that one of the medications, Oxybutynin Chloride extended release, should not be crushed as it could alter its intended release mechanism. The facility's policy requires nursing staff to demonstrate competency in medication management, which includes adhering to physician orders and ensuring medications are administered correctly. The failure to follow these protocols placed the resident at risk of receiving an incorrect dosage and potentially experiencing adverse effects due to the altered release of the medication.
Failure to Create Timely Baseline Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to create a baseline care plan for a resident with diabetes within 48 hours of admission, as required by their policy. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, endocarditis, and chronic kidney disease, did not have a baseline care plan that included the necessary healthcare information to properly care for them immediately upon admission. This omission was identified during a review of the resident's records, which showed that the care plan for diabetes was only initiated several weeks after admission. The Director of Nursing acknowledged that the baseline care plan should have been created within the specified timeframe and should have contained the minimum information needed for the resident's care. The absence of a timely baseline care plan meant that staff lacked a guideline for managing the resident's diabetes, potentially impacting the resident's care. The facility's policy, dated August 2021, clearly stated the requirement for a baseline care plan to be developed within 48 hours of admission, but this was not adhered to in this case.
Failure to Monitor Blood Sugar Levels for Insulin-Dependent Resident
Penalty
Summary
The facility failed to adhere to professional standards of practice for a resident receiving insulin injections by not obtaining and monitoring a physician order for blood sugar levels, as indicated in the resident's care plan. The resident, who was admitted with diagnoses including endocarditis, type 2 diabetes mellitus, and chronic kidney disease, was found to have no blood sugar monitoring orders despite receiving insulin NPH and insulin lispro. This oversight was identified during a review of the resident's order summary report and medication administration record, which showed no indication of blood sugar level monitoring. The deficiency was further highlighted when the resident experienced a change in condition, becoming pale and unresponsive with a blood sugar level of 64 mg/dL, leading to their transfer to a general acute care hospital. Interviews with the Director of Nursing confirmed the absence of blood sugar monitoring orders and the lack of initial assessment per the facility's policy and procedure. The facility's policy required the physician to order appropriate lab tests and incorporate monitoring parameters into the medication administration record and care plan, which was not done for this resident.
Failure to Monitor Vital Signs for Resident with Influenza A
Penalty
Summary
The facility failed to record the respiratory rate, temperature, and oxygen saturation (O2 sat) for one of two residents, identified as Resident 2. This resident was admitted with diagnoses including Influenza A and asthma, conditions that necessitate close monitoring of respiratory parameters. The care plan for Resident 2, dated 1/24/2025, indicated a risk for respiratory complications due to a positive Influenza A result, with a goal to prevent signs and symptoms of respiratory distress. An order was placed on 1/24/2025 to monitor Resident 2's respiratory rate, temperature, and O2 sat every 6 hours starting on 1/25/2025. However, upon review, it was found that several entries were missing from Resident 2's records. Specifically, there were no O2 sat readings documented on 1/25/2025 and 1/26/2025, and multiple entries were missing on 1/27/2025 and 1/28/2025. Similarly, there were missing entries for respirations and temperature on 1/25/2025 and 1/28/2025. During an interview, LVN 1 confirmed the absence of these critical measurements, which were essential for assessing whether Resident 2's flu symptoms were improving or worsening. The facility's policy on Pulse Oximetry, dated 10/2010, requires that O2 sat readings be documented with the date and time, but this was not adhered to in Resident 2's case.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to provide pharmaceutical services to a resident by not ensuring that licensed nurses adhered to the facility's policy and procedure for administering medications within one hour of their prescribed time. This deficiency was identified through interviews and record reviews, which revealed that the resident's medications were frequently administered several hours after the scheduled times. The medications involved included aspirin, famotidine, and atorvastatin, which were prescribed for conditions such as cerebrovascular accident, acid indigestion, and hyperlipidemia, respectively. The resident, who was alert and oriented, required setup assistance for daily activities and had intact cognitive skills for decision-making. Despite this, the Medication Administration Audit Report showed multiple instances where the resident's medications were administered late, ranging from two to six hours past the scheduled times. These delays were consistent over several days and involved both morning and evening doses of the medications. Interviews with the resident and the Director of Nursing confirmed the issue, with the resident expressing that the medications were often given late. The Director of Nursing acknowledged the problem, stating that medications should be administered within one hour of the scheduled time to ensure their effectiveness and minimize side effects. The facility's policy on administering medications also emphasized the importance of timely administration, which was not followed in this case.
Delayed Access to Medical Records Violates Resident Rights
Penalty
Summary
The facility failed to fulfill a request for access to medical records in a timely manner for a resident, which violated the resident's rights. The resident, who was alert and oriented, requested access to his medical records and for them to be sent to his representative. Despite the request being made on 11/18/2024, the records were not sent until 11/26/2024, causing frustration for the resident and his representative. The facility's policy stated that access to records should be provided within 24 hours and copies within two business days, but this was not adhered to. Interviews with the Medical Records Director (MRD), Director of Nursing (DON), and Administrator (ADM) revealed discrepancies in the facility's handling of the request. The MRD stated that records should be released within two business days, but the ADM indicated that no records would be released until payment was received. The DON clarified that electronic records should be free of charge and that the resident should have immediate access to view his records. The delay in releasing the records was attributed to a misunderstanding of the facility's policy and the requirement for payment, which was later waived by the corporate office.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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