Santa Cruz Post Acute

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with a documented bell pepper intolerance received food that accommodated this intolerance. The resident’s dietary interview/pre-screen identified a bell pepper intolerance, and the resident’s tray card listed bell peppers as an allergy. The facility’s Fall/Winter Week 2 menu included sweet and sour pork with steamed rice and an Asian vegetable blend for dinner, and the meal was served with a commercially prepared sweet and sour sauce packet. Ingredient information for the sauce showed it contained dried red and green bell peppers. The registered dietician and dietary director confirmed that this sauce packet, which contained bell peppers, was served with the sweet and sour pork meal. Following consumption of the meal, documentation in the resident’s SBAR Summary for Providers indicated that a CNA reported the resident’s heart was beating fast, with recorded vital signs showing a BP of 150/100 and HR of 136, and the resident was sent to the hospital. An interdisciplinary team progress note documented that the resident mixed the sweet and sour sauce into the rice and then reported mouth numbness and upset stomach. The same note indicated that no clinical findings of an acute allergic response were identified during the hospital emergency room evaluation. Staff interviews confirmed that the resident was known to have an intolerance/allergy to bell peppers and that the sauce packet containing bell peppers was served on the resident’s tray, contrary to the facility’s policy on Food Allergies and Intolerances, which requires identification of allergies/intolerances and prevention of exposure to allergens.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide pressure ulcer and wound care in accordance with physician orders and professional standards for one resident with multiple heel wounds and a sacral pressure ulcer. The resident was admitted and later readmitted in 2025 with blisters on both heels, and the left heel healed by 3/10/25 while the right heel remained open and required ongoing wound treatment. Review of the Treatment Administration Records (TARs) from February through August 2025 showed that wound treatment orders for various heel wounds (including abrasions, blisters, a deep tissue injury, and a diabetic ulcer on the right lateral heel) were not consistently carried out, as evidenced by multiple missing nurse signatures on ordered treatment days. The DON confirmed that if there was no signature, the treatment was not done and acknowledged multiple missed wound treatments on specific dates across several months. The report further describes that the resident developed a stage 2 pressure ulcer on the sacrum that was present upon return from a hospitalization in July 2025. Although the sacral wound was identified on the resident’s return from the hospital, the facility did not obtain a physician’s wound treatment order promptly. As a result, no ordered wound treatment was provided on several days following the resident’s readmission, even though weekly wound assessments later documented dressing changes and treatment beginning on a later start date. The DON confirmed that staff missed obtaining a wound treatment order for the sacral pressure ulcer during this period, and therefore wound treatments were not performed on the specified days. Additionally, the facility failed to develop a care plan to address the resident’s stage 2 sacral pressure ulcer. Review of the resident’s care plans showed no care plan in place for this pressure ulcer, despite facility policies requiring a comprehensive, person-centered care plan with measurable objectives and timetables to meet residents’ needs, and policies on prevention/management of pressure ulcers that call for reviewing the care plan and identifying risk factors and interventions. The DON reviewed the clinical record and confirmed that there was no care plan addressing the sacral pressure ulcer.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow a physician’s order to collect stool specimens for diagnostic testing for a resident who had ongoing diarrhea. The resident was admitted on an unspecified date and nursing progress notes documented that the resident had been experiencing intermittent diarrhea since admission. A physician’s order dated 2/13/25 directed staff to collect stool to rule out C. diff and norovirus. Nursing progress notes on 3/12/25 at 1:25 p.m. stated that the resident was due for a stool culture and C. diff sample to be sent to the lab, but that no bowel movement occurred on the 3 p.m. to 11 p.m. shift and that the sample would need to be collected on the next shift. Subsequent documentation showed that the resident had bowel movements on both shifts on 3/13/25 and again on 3/14/25, as recorded in the Documentation Survey Report V2 for bowel continence. However, there was no further documentation that the ordered stool culture or C. diff sample was ever collected or sent to the lab. During interviews, the DON confirmed that nursing staff did not carry out the physician’s order for the stool culture, and there was no documentation that the physician had canceled or discontinued the order. The facility’s policy on lab and diagnostic test results stated that staff will process test requisitions and arrange for tests, and that concerns about test handling should not prevent timely, clinically appropriate management of a clinical situation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide appropriate treatment and services to prevent UTIs for a resident with an indwelling Foley catheter. The resident had diagnoses including urinary retention, mechanical complication of an indwelling urethral catheter, and type 2 diabetes mellitus with a foot ulcer, and was cognitively intact per an MDS BIMS score of 15. A physician’s order dated 12/22/25 directed staff to collect urine for culture and sensitivity every shift for burning with urination. Nursing notes on 12/23/25 documented the resident’s complaints of bladder pain and dark yellow urine, as well as reports that the resident and family felt staff did not care and that the family frequently requested hospital evaluation for bladder discomfort. Despite the physician’s order, the urine culture was not collected in a timely manner. The DON confirmed that the urine sample for culture was not collected until 12/28/25 at 3:10 a.m., just prior to the resident’s transfer to the hospital, and that there was no endorsement or communication in place to ensure the urine culture would be collected. The DON stated that the nurse who initially received the order no longer worked at the facility and acknowledged that the order should have been followed on 12/22/25. RN A explained that after receiving such an order, it should be entered into the electronic health record and, if not completed, endorsed to the next shift. The case manager later stated that the urine culture should have been done sooner to determine the best antibiotic treatment and to prevent the resident’s emergency department visit, and hospital records showed a positive urinalysis and diagnosis of UTI and cystitis, with IV antibiotics administered and the Foley catheter changed. A separate deficiency was identified related to catheter care technique. During an observation on 2/23/26, the resident’s urine collection bag connected to the Foley catheter was found placed on the floor. A CNA present in the room confirmed that the bag should not be on the floor and stated it should be secured on the bed rail above the floor and below the level of the bladder to prevent infections. Review of the facility’s catheter care policy dated 8/2022 specified that catheter tubing and drainage bags must be kept off the floor and that the drainage bag must be positioned lower than the bladder at all times. This observation showed staff did not follow the facility’s catheter care policy for maintaining proper positioning of the drainage bag.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident dependent on renal dialysis and with difficulty walking was transported to a dialysis appointment in the facility van, which lacked the required safety equipment and was operated by unqualified and untrained staff. The van did not have a shoulder harness as required by federal regulations, only a lap belt, and the wheelchair securement system did not meet ADA Accessibility Specifications for Transportation Vehicles. The maintenance aide, who was not a certified nursing assistant and had not completed the required Facility Vehicle Driver Training Program or pre-trip inspection, was instructed to transport the resident despite expressing discomfort and lack of experience. During transport, the aide improperly secured the wheelchair, resulting in the wheelchair tipping and the resident falling forward, striking her head and sustaining a skin tear. After the fall, the aide did not immediately inform the dialysis facility staff of the incident, and the resident proceeded with her dialysis appointment without assessment for injury at that time. Upon return to the facility, the resident was found to have a head injury and a skin tear, and was subsequently sent to the emergency department for evaluation. The emergency department documented a closed head injury, moderate to severe pain, and possible concussion symptoms. The facility's records confirmed that the staff members assigned to drive the van were not CNAs as required by the facility's job description, and had not completed or documented the necessary training prior to transporting residents. Interviews with facility staff and review of documentation revealed that the van's securement system was not compliant with federal safety standards at the time of the incident, and that the required pre-trip inspection and training protocols were not followed. The maintenance aide admitted to not knowing how to properly secure the resident and not performing the required safety checks. The facility's own policies required CNA certification, CPR certification, and completion of a vehicle driver training program for anyone transporting residents, none of which were met in this case. The lack of proper equipment, training, and communication led directly to the resident's fall and injury during transport.

Penalty

Fine: $127,715

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to ensure the safety of a resident during in-bed care. The resident, who had severe cognitive impairment, was dependent on staff for all self-care and mobility activities, and had impairments in one upper and both lower extremities. During routine in-bed care, a CNA rolled the resident to the side of the bed without the required assistance of a second staff member, resulting in the resident falling from the bed onto a floor mat. The fall led to comminuted fractures of the right tibia and fibula, necessitating hospital transfer. The facility also failed to accurately complete the resident's fall risk assessment. Despite a documented unwitnessed fall within the previous 90 days, the assessment did not reflect this incident, resulting in an inaccurate fall risk score. Facility policy required that nursing staff review the resident's record for a history of falls, especially within the last 90 days, but this was not properly followed. Additionally, the facility did not implement the resident's care plan intervention to ensure proper positioning in bed. The care plan, which identified the resident as being at risk for falls due to multiple factors including confusion, gait and balance problems, and muscle atrophy, included an intervention to ensure the resident was properly positioned in bed. Staff failed to follow this intervention during the in-bed care that led to the fall and injury.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain informed consent for psychotropic medications from the appropriate responsible party for a resident diagnosed with toxic encephalopathy and dementia. The resident's clinical record indicated that the responsible party was a conservator, but the informed consent for psychoactive medications was instead obtained verbally from a case worker. The case worker was listed as a contact but was not authorized to make medical decisions for the resident. Interviews with facility staff and the case worker confirmed that the conservator was the designated responsible party and that the case worker did not have the authority to provide consent for medical treatments. The facility's policy required that staff and physicians review treatment options and obtain documented consent from the resident or their representative prior to initiating or changing psychotropic medications, but this process was not followed in this instance.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement comprehensive care plans for 11 of 40 sampled residents, which placed these residents at risk of not receiving appropriate, consistent, and individualized care. The deficiency was identified through interviews and record reviews, revealing that care plans were not developed for residents with specific medical conditions and medication needs. For instance, Resident 104 was admitted with heart failure and had a physician's order for amiodarone to treat arrhythmia, yet no care plan was developed for this condition or medication use. Similarly, Resident 38, who was admitted with heart failure and had orders for digoxin and amiodarone, lacked a comprehensive care plan addressing these medications and their associated conditions. The Minimum Data Set Coordinator confirmed the absence of care plans for these critical health issues. Other residents, such as Resident 111 and Resident 287, also had no care plans for their heart-related conditions and prescribed medications, despite having physician orders for digoxin. The deficiency extended to other residents, including Resident 10, Resident 54, and Resident 121, who were admitted with various heart conditions and prescribed medications like digoxin and amiodarone. The facility's failure to develop care plans for these residents was confirmed through interviews with staff members, including the Director of Nursing and the Assistant Director of Staff Development. The facility's policy on comprehensive, person-centered care plans was not adhered to, as evidenced by the lack of measurable objectives and timetables to meet the residents' needs.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to monitor and document the weights of a resident, identified as Resident 34, for three consecutive months. Despite having a physician's order for monthly weight checks starting from April 2024, there were no records of weights for December 2024, January 2025, and February 2025. This oversight was confirmed by the Assistant Director of Staff Development (ADSD) and the Director of Nursing (DON), who acknowledged the absence of weight records and the failure to adhere to the physician's order. Another deficiency involved Resident 124, who had a STAT order for an x-ray of the left knee due to pain, which was not executed in a timely manner. The order was placed on February 25, 2025, but the x-ray had not been completed by the following day. The Minimum Data Set Coordinator (MDSC) and the DON confirmed that the STAT order, which should have been completed within 4-6 hours, was not followed up with the diagnostic laboratory, resulting in a delay. Additionally, the facility did not adhere to the physician's order for Resident 5's gastrostomy tube feeding. The order specified a water flush of 130 mL every six hours, but observations revealed that the feeding pump was set to flush every four hours. This discrepancy was confirmed by the Director of Staff Development (DSD), who acknowledged that the setup did not match the physician's order. The facility's policy on enteral feedings emphasizes the importance of checking the enteral nutrition label against the order to prevent administration errors.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care and services for a resident with an indwelling catheter, as there was no documented catheter care for several days and shifts over a three-month period. The resident, who was admitted with diagnoses including a wedge compression fracture, dementia, and a history of urinary tract infections (UTIs), had an order for catheter care to be performed every shift. However, the treatment administration records (TAR) for December 2024, January 2025, and February 2025 showed multiple instances where catheter care was not documented, indicating it was not performed. During interviews, both the Minimum Data Set Coordinator and the Director of Nursing confirmed the lack of documentation and stated that if catheter care was not documented, it was not done. The Centers for Disease Control and Prevention's guidelines for preventing catheter-associated urinary tract infections emphasize the importance of routine hygiene and proper documentation. The failure to document and perform catheter care had the potential to lead to catheter-associated urinary tract infections for the resident.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the proper use of bed rails for 29 out of 63 residents who used them. The deficiencies included the absence of informed consent for four residents, outdated or missing bed rail assessments for three residents, lack of care plans for 18 residents, and missing physician orders for 21 residents. These failures were identified through observations, interviews, and record reviews conducted by surveyors. In several instances, residents were using bed rails without the necessary informed consent. For example, Resident 91 had been using bed rails without documented consent, and the facility staff confirmed that they could not find the consent in the resident's medical records. Similarly, Residents 114, 45, and 59 were observed with bed rails in use, but no signed consents were found in their medical records. The facility's regional director of clinical services (RDCS) confirmed these findings during interviews and record reviews. Additionally, the facility did not update bed rail assessments in a timely manner for some residents. Resident 287's bed rail assessment had not been updated since May 2023, and Resident 29's assessment was not completed after the initial one. Furthermore, many residents were using bed rails without having a care plan in place. For instance, Residents 302, 15, 40, and others had their side rail care plans created only after the surveyors' observations. The RDCS and the director of nursing acknowledged these deficiencies during interviews.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff on a 24-hour basis, as evidenced by the Staffing Data Report submitted to the Centers for Medicare & Medicaid Services (CMS). A review of the facility's Direct Care Service Hours Per Patient Day (DHPPD) from July 2024 to January 2025 revealed that on 63 days, the actual DHPPD fell below the required 3.5 hours. This deficiency was confirmed during an interview with the Staffing Coordinator, who acknowledged the staffing challenges and confirmed that the DHPPD for those days were indeed below the required threshold. The facility had a workforce shortage waiver, which allowed for some flexibility in staffing requirements, but it still mandated a minimum of 3.5 direct care service hours per patient day. Despite this waiver, the facility did not meet the required staffing levels, as confirmed by the Administrator. The waiver from the California Department of Public Health specified that the facility must provide no less than 3.5 DHPPD, and the All Facilities Letter reiterated that this is a minimum requirement for Skilled Nursing Facilities. The failure to meet these staffing requirements could potentially affect the care, health, and psychosocial well-being of the residents.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nursing staff demonstrated competency in the assessment and management of antihypertensive and antiarrhythmic medications for 11 out of 40 sampled residents. This deficiency was identified through observations, interviews, and record reviews, revealing that blood pressure (BP) and heart rate (HR) were not consistently checked before medication administration, and physician's orders and prescribed hold parameters were not followed. For instance, a Licensed Vocational Nurse (LVN) administered losartan to a resident without checking the BP, contrary to the physician's order to hold the medication if systolic BP was less than 110 mmHg. Further investigation into the medication administration records (MARs) of another resident revealed that nursing staff documented the administration of multiple medications without corresponding BP and HR readings, despite physician orders requiring these checks. The Director of Nursing (DON) and other staff acknowledged that BP and HR were not checked daily as required, and there were significant gaps in documentation. This lack of adherence to physician orders and documentation protocols had the potential to result in undetected severe hypotension and arrhythmias. Additionally, the facility failed to ensure that all nursing staff were checked off on their competencies to provide nursing care and medication pass training. One of the five nurses reviewed did not have a record of being checked off on these competencies, which could compromise resident safety and their ability to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The facility's policy and procedures require that medications be administered in accordance with prescribers' orders, including necessary vital sign checks, which were not consistently followed in this case.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate pharmaceutical services, resulting in several deficiencies related to medication availability, administration, and accountability. Resident 296 did not receive the prescribed medication Steglatro for 10 days due to insurance issues and lack of follow-up by the nursing staff. The medication was not available, and the staff failed to notify the physician or ensure an alternative was provided in a timely manner. This oversight was confirmed by the Nursing Supervisor, who acknowledged the absence of documented follow-up actions. Additionally, Resident 296 received crushed medications that should not have been altered, including Metoprolol ER and Protonix, which are formulated for extended or delayed release. The nursing staff, including RN F, acknowledged the error but continued to administer the medications inappropriately, potentially compromising the resident's treatment. The facility's policy on crushing medications was not adhered to, as confirmed by interviews with the nursing staff and the consultant pharmacist. Resident 6 experienced difficulties with medication administration due to swallowing issues, yet there was no individualized care plan to address this. The potassium chloride ER tablet was crushed and administered incorrectly, contrary to manufacturer instructions. The facility also lacked a system to ensure the proper application and monitoring of narcotic patches, as evidenced by the case of Resident 297, whose buprenorphine patch was not accounted for. Furthermore, controlled medications were not properly reconciled for several residents, leading to discrepancies in medication records and potential for misuse. These findings were confirmed by the Director of Nursing and Medical Record Director during the survey.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for several residents. For Resident 296, the CP did not report that medications such as metoprolol ER and Protonix, which should not be crushed, were being crushed and administered inappropriately. Additionally, the CP failed to follow up on a recommendation to discontinue omeprazole due to duplicate therapy with Protonix, leading to unnecessary medication use. Resident 104's medication regimen was not properly monitored, as blood pressure (BP) and heart rate (HR) were not checked daily as required by physician orders. The resident was receiving multiple antihypertensive medications and amiodarone without appropriate monitoring, increasing the risk of hypotension and arrhythmias. The CP did not make recommendations for monitoring BP and HR, nor was there a care plan developed for the resident's heart failure and amiodarone use. For residents receiving digoxin, the facility failed to develop comprehensive care plans and did not monitor digoxin levels as required. Residents 38, 111, 287, 10, 54, and 121 were all affected by this oversight. The CP did not make recommendations for routine digoxin level monitoring or care plan development, which are crucial for managing the narrow therapeutic index of digoxin and preventing toxicity.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that 13 out of 40 sampled residents were free from unnecessary medications due to inadequate monitoring and systemic failures in the management of antihypertensive and antiarrhythmic medications. Licensed Vocational Nurse C did not measure Resident 47's blood pressure before administering losartan, an antihypertensive medication. Similarly, Resident 104 did not have daily blood pressure and heart rate monitoring as ordered, despite receiving multiple antihypertensive medications and amiodarone, an antiarrhythmic agent. The Medication Administration Record was not coded correctly to require input of the necessary vital signs before medication administration, leading to significant gaps in monitoring. For residents receiving digoxin, an antiarrhythmic agent, there were multiple instances where heart rate was not checked or was outside the prescribed parameters, yet the medication was still administered. Resident 38 received digoxin six times when the heart rate was outside the prescribed parameter, and Resident 111 had no heart rate obtained on a day when digoxin was given. Additionally, there was a lack of comprehensive care plans for residents using digoxin, and the facility's consultant pharmacist failed to identify and report these irregularities. The facility also failed to document necessary monitoring for residents receiving amiodarone, including blood pressure and heart rate checks prior to administration. Resident 72 received amiodarone with a blood pressure reading that should have prompted the medication to be held and the physician notified. Furthermore, there was no evidence of monitoring for signs and symptoms related to the use of anticoagulants for Residents 39 and 53, which could lead to adverse effects. These systemic failures in monitoring and documentation had the potential to cause significant harm to the residents.

Removal Plan

• The facility identified residents whose BP and HR need to be monitored. All residents with antihypertensive and antiarrhythmic medications have their updated orders for BP and/or HR check prior to administration, hold parameters, BBW monitoring, digoxin level (when applicable), and developed comprehensive care plan.
• The DON or RDCS in-serviced/trained clinical leadership members, and licensed nurses on ensuring that residents with anti-hypertensive and antiarrhythmic medications have orders for BP and/or HR check prior to administration, hold parameters, BBW monitoring order, digoxin level (when applicable) is carried out, and care plan is developed for use of those medications. LNs who are on vacation or leave and any new registry licensed nurses will be provided in-service/competency training before they work on the floor.
• The CP was provided an in-service by his supervisor on reviewing and identifying medication irregularities during monthly medication regimen review. The CP performed an audit of all residents on anti-hypertensive and antiarrhythmic medications for any inconsistencies on BP and/or HR checks prior to medication administration and on applicable lab test recommendations for those medications.
• The interdisciplinary team (IDT) will continue to conduct a daily review of new admissions orders and any new orders for anti-hypertensive and antiarrhythmic medications and verify that those required components are present and being followed.
• The clinical leadership team started with random observation of several LNs during medication pass to ensure that BP and/or HR are checked prior to giving medication(s) and hold parameters are followed.
• The Medical Director has been actively consulted and involved by the clinical leadership team on ensuring that all residents receiving medications have appropriate vital signs monitoring and checks, have hold parameters, and applicable lab orders for use of medications.
• The Medical Records Director (MRD) or designee will continue to perform compliance audits to ensure that residents with anti-hypertensive and antiarrhythmic medications have orders for BP and/or HR check prior to administration, hold parameters, black box monitoring, digoxin level (when applicable), and care plan.
• Corrective Action Plan will be reviewed at QAPI Committee Meeting using pertinent compliance audit information and resolutions until the desired outcome of 100% compliance is achieved and sustained for at least six consecutive months.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that three residents were free from unnecessary psychotropic medications. Resident 45 received PRN lorazepam beyond the 14-day limit without a physician-documented clinical rationale or a specified duration for the extended period. During an interview, facility staff acknowledged the oversight but could not provide documentation justifying the extension of the PRN order. Resident 107 was administered Depakote and quetiapine without proper monitoring for side effects or necessary laboratory tests, such as A1c and lipid panels, which are crucial for patients on antipsychotic medications. The absence of monitoring was confirmed during a review of the resident's clinical record, and the nursing supervisor acknowledged the lack of side effect monitoring and the need for further investigation into the missing lab tests. Resident 104 received PRN lorazepam and Seroquel beyond the 14-day limit without appropriate documentation. Additionally, the routine use of Seroquel was not supported by a suitable indication, as the care plan cited insomnia and altered mental status, which are not appropriate indications for antipsychotic use. Facility staff confirmed the discrepancies in the resident's clinical record and acknowledged the inappropriate indications for the medication use.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to have a medication error rate of 12.12%, exceeding the acceptable threshold of 5%. This was observed during medication administration for three residents. Resident 296 received crushed metoprolol ER, which should not be crushed due to its extended-release formulation. The nurse acknowledged the error but continued to administer the medication in a crushed form, as the resident preferred it that way. The consultant pharmacist confirmed that metoprolol ER should not be crushed. Resident 6 experienced two medication errors. First, the resident was given potassium chloride ER in a crushed form, contrary to the manufacturer's instructions. The nurse acknowledged the error after reviewing the pharmacy label and the manufacturer's guidelines. Additionally, Resident 6 did not receive a scheduled dose of senna, a laxative, during the morning medication administration. The nurse admitted the oversight upon reviewing the resident's physician orders. Resident 47 received an incorrect dose of vitamin C, receiving 1,000 mg instead of the prescribed 500 mg. The nurse mistakenly thought the vitamin C bottle contained 250 mg tablets, leading to the administration of two tablets. Upon review, the nurse confirmed the error. The facility's policies on medication administration and crushing were not adhered to, contributing to these errors.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper storage and labeling of medications across multiple medication carts and rooms. During an inspection of Station 4 Medication Cart, it was found that several medications, including eye drops and inhalers, were either not labeled with open dates or were being used past their discard dates. For instance, an eye drop bottle for a resident did not have an open date, and another had an open date indicating it was expired. Additionally, an inhaler was found to be expired, and an insulin vial was past its discard date. These issues were confirmed by the licensed vocational nurse present during the inspection. Further inspections revealed similar deficiencies in other areas. At Station 1 Medication Cart, a bottle of senna syrup was found to be expired. At Station 2B Medication Cart, multiple insulin vials were either missing open date labels or had incorrect expiration dates. An eye drop bottle and an inhaler were also found to be used past their discard dates. These findings were confirmed by the nursing supervisor present during the inspection. In the Station 2 Medication Room, an opened tuberculin vial was found without an open date, and in the Automated Dispensing Unit Medication Room, a refrigerator was set below the acceptable temperature range, potentially compromising the integrity of stored vaccines. The assistant director of nursing confirmed these findings. The facility's policies and procedures for medication storage and labeling were not adhered to, as evidenced by the presence of outdated and improperly stored medications.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the palatability and nutritive value of cooked foods, as evidenced by complaints from three residents about the bland taste of their meals. Resident 16, who was on a no added salt diet due to unspecified gout, Resident 88, with Alzheimer's disease on a regular diet with mechanical soft texture, and Resident 15, with cerebral ischemia on a pureed diet, all reported that their food tasted bland. Test trays confirmed that both regular and pureed foods lacked flavor, which was verified by the cook and dietary manager. Additionally, the preparation of pureed foods was mishandled, as they were held in a heated oven for over an hour before being served, potentially compromising their nutritive value. Cook M prepared pureed rice and vegetables at 10:30 a.m., but they were not served until after 11:40 a.m., exceeding the recommended holding time. This was acknowledged by Cook M, the dietary manager, and the registered dietitian, who confirmed that such practices could affect the food's quality. Furthermore, the recipe for pureed ground beef was not followed correctly. Cook M did not use the specified #6 scoop for measuring the beef and added water instead of broth or gravy, which could dilute the flavor. This deviation from the standardized recipe was confirmed by Cook M, the dietary manager, and the registered dietitian, who noted that the use of water instead of the recommended liquids could result in a poorly accepted product.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food safety by not labeling food items with open and use-by dates. During a kitchen tour, it was observed that packets of sugar, chocolate powder, coffee creamers, coffee powders, tea, and cookie bars were removed from their original packaging and stored in containers without proper labeling. The assistant dietary manager confirmed the absence of labels, and the registered dietitian acknowledged the need for labeling, as per the facility's policy. This oversight could potentially lead to the growth of microorganisms, posing a risk of foodborne illness to the 138 residents receiving meals from the facility's kitchen. Additionally, a cook assistant was observed not wearing his face mask properly while preparing desserts, with his nose exposed. This was confirmed by the assistant dietary manager and acknowledged by the cook assistant, who corrected the mask placement immediately. The registered dietitian confirmed that kitchen staff should wear masks properly, in line with the facility's policy requiring mask use during the respiratory virus season. These deficiencies highlight lapses in adherence to food safety and infection control protocols.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement proper infection control measures, as evidenced by several observations and interviews. In Resident 287's room, a pair of used gloves was found on the floor, which the Director of Nursing (DON) confirmed should have been disposed of in a designated waste receptacle. Additionally, Resident 72's used urinal was improperly placed on the overbed table, which the nurse supervisor confirmed should have been hung at the side of the bed to prevent contamination of surfaces used for meals and drinks. Further deficiencies were noted in the improper labeling, cleaning, and storage of residents' personal care items such as basins, bedpans, urinals, and water pitchers. These items were found unlabeled and stored on bathroom floors or in inappropriate locations, which was confirmed by various staff members, including certified nursing assistants and licensed vocational nurses. The facility's policy requires these items to be labeled, cleaned, and stored properly to prevent cross-contamination among residents sharing bathrooms. Additional infection control lapses included staff failing to perform hand hygiene between tasks, such as meal setups and medication administration. Certified Nursing Assistant P did not sanitize hands between serving meals to different residents, and nursing staff were observed handling medication capsules without gloves. Moreover, a medication cart was found with unsanitary conditions, and a PICC line dressing for Resident 338 was not changed as per the physician's order, increasing the risk of infection. Lastly, a bag of dirty linens was left on the hallway floor, which the Infection Preventionist acknowledged should not have occurred to prevent the spread of infection.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain respect and dignity for three residents by not covering their indwelling catheter urinary bags with privacy bags and by posting personal information in a shared room. Resident 46's urinary bag was observed exposed and not covered with a privacy bag, despite the clinical record and care plan indicating that it should be covered to promote dignity. Similarly, Resident 296's urinary bag was also exposed and visible to passersby, which was confirmed by RN F, who acknowledged that the urinary bags should have been covered. The facility's policy on dignity, revised in February 2021, explicitly states that urinary catheter bags should be covered to maintain residents' dignity. Additionally, Resident 133's personal information and care guide were posted on the wall above the head of the bed, visible to the roommate's visitors. This included details about dietary restrictions and swallowing precautions. RN F confirmed that this information should have been covered, and the DON acknowledged that care instructions should not be openly posted unless specifically requested by the resident or family member. The facility's policy on dignity also emphasizes the protection of confidential clinical information, indicating that signs of clinical status or care needs should not be openly posted in the resident's room.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its policy and procedure on self-administration of medication, resulting in medications being left at the bedside for two residents without proper documentation or physician orders. Resident 113, who was admitted with diagnoses including low back pain, opioid use, and chronic pain syndrome, was observed with a bottle of lidocaine pain relief roll-on at his bedside, which he used for knee pain. However, there was no physician order for this medication, nor was there an assessment for self-administration, as confirmed by LVN K. The facility's policy requires a physician's order and a self-administration assessment for medications to be kept at the bedside, which was not followed in this case. Similarly, Resident 44, who was admitted with diagnoses including spondylosis of the lumbar region, mild cognitive impairment, and failure to thrive, was found with two bottles of wound cleansers on her overbed table. She used these cleansers to wash her hands after using the bedside commode. LVN K confirmed that these wound cleansers should not have been at the bedside and should have been stored in the treatment carts. The Director of Nursing reiterated that medications should not be left at the bedside unless deemed safe for self-administration, documented in the care plan, and stored securely, which was not the case for these residents.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the needs of Resident 296 were accommodated when the call button was not within the resident's reach. Resident 296, who was admitted with a nondisplaced fracture of the left tibial tuberosity, repeated falls, and difficulty walking, had a moderate cognitive impairment with a BIMS score of 11. During an observation and interview, Resident 296 was found eating breakfast in bed and expressed that he did not know where his call button was located. The call button was observed on the floor near the bed's wheels, out of the resident's reach. Registered Nurse F confirmed the observation and acknowledged that the call button should have been within the resident's reach. The Director of Nursing also stated that call buttons should always be accessible to residents. The facility's policy, revised in September 2022, indicated that residents should have a means to call staff for assistance from their bed. This oversight had the potential to delay response times and hinder the timely meeting of Resident 296's needs.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete a comprehensive Minimum Data Set (MDS) admission assessment and a required discharge assessment in a timely manner for one resident. The resident was admitted to the facility with diagnoses including osteoarthritis, chronic obstructive pulmonary disease, and asthma. The MDS admission assessment, which should have been completed by the 14th day of admission, was completed late. Specifically, the assessment was due on the 14th day following the resident's admission but was not completed until several days later. Additionally, the facility did not complete the MDS discharge assessment within the required timeframe. The resident was discharged to home, and the discharge assessment was due 14 days after the discharge date. However, the assessment was completed late, missing the required deadline. These delays in completing the MDS assessments had the potential to result in inappropriate care planning and intervention for the resident.

Penalty

Fine: $27,615

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with Federal and State laws and regulations by not posting the approval letter for a staffing waiver where visitors and residents could easily read it. During an observation on February 28, 2025, at 11:54 a.m., it was noted that the approval letter was not displayed on the facility's glass-covered cork board. The facility administrator confirmed during an interview that the letter should have been posted there. Additionally, the staffing coordinator acknowledged the existence of a staffing waiver. The approval letter, dated June 18, 2024, specified that it should be posted immediately adjacent to the facility's license and that residents should be provided with a true copy of the letter prior to the execution of an admission agreement.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate and necessary services in accordance with professional standards of practice for three residents. For Resident 1, the skin and wound assessment was incomplete, and the Nursing Care Plan (NCP) was not specific to the wound status. Additionally, the facility's Licensed Nurses (LNs) did not recheck and notify the physician for abnormal low blood pressure measurements. Resident 1 was admitted with multiple diagnoses, including dementia and difficulty walking, and was at risk for developing pressure ulcers. The skin and wound assessment conducted by the Assistant Director of Nursing/Licensed Vocational Nurse (ADON/LVN) was incomplete, missing critical information such as the location of the wound and evidence of infection. Furthermore, the facility staff failed to recheck Resident 1's low blood pressure readings and did not notify the physician, which was confirmed by the Director of Nursing (DON). For Resident 2, there was no evidence of documentation that the physician was notified and a treatment order was obtained for a right gluteus abrasion. The facility also failed to provide treatment for the abrasion from the day after the wound assessment until the resident was discharged. Resident 2 was admitted with diagnoses including spondylosis and difficulty walking. The Treatment Nurse (TN B) confirmed that there was no documentation of notifying the physician or obtaining a treatment order, and no treatment was recorded in the Treatment Administration Record (TAR). The DON acknowledged that the NCP should have been developed for Resident 2's abrasion, and the physician should have been notified about the medication unavailability. Resident 3 experienced an unwitnessed fall, but there was no documentation regarding how the fall occurred, and the Interdisciplinary Team's (IDT) post-fall notes were incomplete. Resident 3 was readmitted with diagnoses including dementia and a history of repeated falls. The Fall Risk Assessment indicated a high risk for falls. The DON confirmed that the documentation for the fall incident and IDT notes were incomplete, lacking details on how the fall happened and the root cause investigation. This lack of documentation hindered the development of effective recommendations for Resident 3's NCP for fall prevention.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide and communicate necessary information regarding a pending laboratory workup for a resident who was transferred to another facility. The resident, who had been diagnosed with an overactive bladder and a urinary tract infection, was discharged without the receiving facility being informed of a pending urinalysis and culture and sensitivity test. The urine specimen had been collected and sent to the laboratory prior to the resident's discharge, but the results, which indicated the presence of bacteria, were not communicated. The Licensed Vocational Nurse (LVN) responsible for the discharge was unaware of the pending laboratory workup and did not convey this critical information to the receiving facility. The Director of Nursing confirmed the lack of documentation and communication regarding the pending urinalysis. The facility's policy requires that all necessary information, including recent lab tests, be communicated to ensure a safe and effective transition of care, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate Activities of Daily Living (ADL) care for a resident, specifically in ensuring that scheduled showers or bed baths were given. The resident, who had an above-the-knee amputation, difficulty walking, and obesity, required partial/moderate assistance with bathing. Despite having a preference for showers or bed baths on specific days, there was no evidence in the records that these were provided on three consecutive scheduled days. Interviews with the resident confirmed that she did not refuse the showers or bed baths on those days. The deficiency was further highlighted by the lack of proper documentation by the certified nursing assistants (CNAs) responsible for the resident's care. CNA A admitted to incorrectly marking 'NA' in the ADL bathing record, while CNA B and CNA C were unsure if they provided the care and failed to document it properly. The Director of Staff Development and the Director of Nursing acknowledged the documentation errors and the need for accurate record-keeping. The facility's policies and procedures emphasized the importance of documenting care provided, but these were not followed, leading to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that three nursing assistants, identified as NA A, NA B, and NA C, completed their state certification program, including the necessary examination to test their knowledge and skills. This resulted in these individuals working as Certified Nurse Assistants (CNAs) without proper certification, which could potentially compromise resident safety. The California Department of Public Health Licensing and Certification Verification Search Page confirmed that these nursing assistants did not have active CNA certifications. NA A was hired with the expectation of obtaining certification, as indicated in her hire letter and job description, but she had been working for six months without completing the certification process. Similarly, NA B and NA C were hired under the same conditions but had not yet taken the required skills and written tests. Despite this, they were assigned to care for residents independently, as evidenced by the facility's staffing schedules and sign-in sheets. Interviews with the nursing assistants revealed that they were aware of their uncertified status, yet they continued to perform duties typically assigned to certified CNAs. The facility administrator confirmed that these nursing assistants were providing care without having completed the necessary certification tests, acknowledging that this should not have occurred. According to the Healthcare Professional Certification Program, individuals can only work as nursing assistants for up to 120 days while certification requirements are pending, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide proper supervision for a resident when a nurse aide, who did not have the required certification to work as a certified nursing assistant (CNA), assisted the resident out of the shower room alone. This resulted in the resident's fall. The resident had been admitted with diagnoses including an intraspinal abscess and difficulty in walking, and was assessed as dependent on others for tub/shower transfers, requiring the assistance of two or more helpers. Despite this, the uncertified nursing assistant attempted to transport the resident alone, leading to the resident slipping from the shower chair and falling onto the floor. The nursing assistant involved had been working at the facility for six months and was in the process of obtaining her CNA certification. However, she was assigned to care for residents independently before completing the necessary certification tests. The facility's director of nursing and administrator confirmed that the nursing assistant should not have been working in patient care without certification, and that the safest way to handle a resident larger than the caregiver is to have assistance. The facility's hiring and job description documents indicated that certification was a requirement, yet the nursing assistant was allowed to work without it.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care and services for a resident with an indwelling catheter. The resident was admitted with a displaced intertrochanteric fracture of the right femur and had an indwelling catheter as indicated in the Minimum Data Set. However, there was no physician's order for the catheter, and the resident's care plans did not include a urinary catheter care plan. The medical records lacked documentation of urinary catheter care, including assessments of urine output and characteristics such as color, clarity, and odor. Additionally, there was no record of the number of times the resident voided, as required by the physician's order for bladder training. This order specified that staff should ensure the resident was voiding and document the number of voids every shift for five days, but this was not done. The Director of Nursing confirmed these deficiencies during an interview, acknowledging the absence of a physician's order for the catheter, a catheter care plan, and documentation of urine output and catheter care. The facility's policies on care plans and urinary catheter care were not followed, as they require comprehensive assessment information to derive care plan goals and detailed documentation of catheter care and urine characteristics.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nurses documented the admission for one of the residents, resulting in an incomplete medical record. The resident in question was admitted with a displaced intertrochanteric fracture of the right femur. Upon review, it was found that there was no admission assessment or narrative admission notes recorded at the time of the resident's admission. This lack of documentation was confirmed during an interview with the Director of Nursing (DON), who acknowledged the absence of these critical records. The facility's policy on Admission Notes, revised in September 2012, requires that the admitting nurse document specific information when a resident is admitted. This includes the date and time of admission, the source of admission (such as a hospital or home), and the general condition of the resident upon arrival. The policy emphasizes that this initial information-gathering is essential and should precede the complete history and physical assessment that accompanies the admission process. The failure to adhere to this policy resulted in an incomplete medical record for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a care plan to address the use of a Foley catheter for two residents, which was identified during a survey. Resident 1 was admitted with multiple diagnoses, including hypertensive heart disease with heart failure, acute respiratory failure with hypoxia, and obstructive and reflux uropathy. Despite having a physician's order to insert a Foley catheter on 9/17/23, there was no care plan developed to address this need. During interviews, both the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) acknowledged the absence of a care plan for the Foley catheter, which was necessary for staff to know how to care for it. Similarly, Resident 2, who was admitted with conditions such as fusion of the spine cervical region, essential hypertension, muscle wasting, and dysphagia, also had a Foley catheter inserted on 6/10/24 without a corresponding care plan. The Nursing Supervisor and the ADON confirmed the lack of a care plan for the Foley catheter during interviews. The facility's policy on comprehensive, person-centered care plans, dated 3/22, requires that care plans include measurable objectives and timetables to meet residents' needs, which was not adhered to in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide care and services in accordance with professional standards for a resident who was admitted with multiple diagnoses, including a recent posterior spinal fusion and decompression surgery. The discharge instructions from the acute hospital specified that sutures or staples should be removed within 7-10 days. However, the facility did not transcribe this order, resulting in the sutures being removed later than recommended. Interviews with the Wound Nurse, Nursing Supervisor, Director of Nursing, and Assistant Director of Nursing confirmed that the sutures were not removed within the specified timeframe and that there was no documentation of the wound being checked. Additionally, the facility inserted a foley catheter for the same resident without a physician's order, as confirmed by the Nursing Supervisor and Assistant Director of Nursing. The facility's policy requires a physician's order for foley catheter insertion, which was not obtained in this case. This oversight was identified during a review of the resident's progress notes and interviews with facility staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor the requests of two residents for showers, which is a violation of their right to self-determination. Resident 2, who has a cognitive score indicating she is mentally intact, reported missing showers on her scheduled days and was denied a bed bath due to staff being too busy. Her clinical record showed no documentation of showers or bed baths being provided on multiple scheduled days. Similarly, Resident 3, also cognitively intact, reported missing showers on some Saturdays and was told by staff that they were too busy to provide a shower. Her records also lacked documentation of showers or bed baths on several scheduled days. The facility's policies on resident rights and bathing procedures emphasize the importance of honoring resident preferences and documenting care, which was not adhered to in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards of practice by not following a physician's order for 1:1 monitoring of a resident with severe cognitive impairment and a history of altercations. The resident, who was diagnosed with dementia, neurosyphilis, and unsteadiness on feet, had a care plan that included 1:1 monitoring to ensure the safety of other residents. Despite the physician's order for continuous 1:1 monitoring every shift, documentation revealed that the facility did not assign staff for 1:1 monitoring during the night shift from early June to late July. Interviews with the staffing coordinator, administrator, and director of nursing confirmed the lack of 1:1 monitoring during the night shift, as the resident was assumed to be sleeping. The facility did not evaluate the resident's behavior or communicate with the physician to adjust the monitoring schedule, which was acknowledged as a necessary step by the administrator and director of nursing. The facility's policy on behavioral assessment and monitoring emphasized the need for comprehensive assessment and documentation of any changes in behavior, which was not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its bed rail policy for one resident, resulting in several deficiencies. There was no documentation indicating that alternatives to bed rails were attempted before their installation. Additionally, the facility did not document that the risks and benefits of using bed rails were explained to the resident or their responsible parties, nor was informed consent obtained. Furthermore, the facility did not assess the risk of entrapment or evaluate the bed dimensions to ensure they were suitable for the resident's size and weight before installing the bed rails. During an observation, it was noted that the resident's bed had bilateral upper partial bed rails in place. The facility's policy requires that bed frames, mattresses, and bed rails be checked for compatibility and size prior to use, and that residents or their representatives be informed about the benefits and potential hazards associated with bed rails. However, these steps were not documented as having been completed for the resident in question, potentially placing the resident at risk of entrapment and serious injury.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide written notice to two residents prior to a room change and did not document the room change in the medical records for six residents. This lack of documentation and communication potentially affected the residents' emotional and psychosocial well-being. Resident 1 reported being informed of a room change without signing any agreement, contrary to previous experiences. Resident 2's family member also stated that they were not given a choice or any written notice regarding the room change. Interviews with facility staff revealed inconsistencies in the follow-up process after room changes. Licensed vocational nurses acknowledged the need to document room changes and monitor residents' acclimation, but this was not done. The admissions coordinator and social services director provided conflicting accounts of the follow-up procedures, with some staff unaware of the requirement for social services to document psychosocial checks. The facility's policy and job descriptions outlined the need for advance notice and documentation of room changes, which were not adhered to in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision and assistance to a resident who was dependent on staff for transferring, resulting in the resident falling and sustaining a laceration on her forehead. The resident, who had a history of falling and was at high risk for falls, was left unsupervised in her room after being brought back from a group activity. The resident attempted to self-transfer without staff assistance, leading to the fall. The resident's care plan indicated a need for staff participation in transfers due to impaired balance and limited mobility. The resident's MDS assessment confirmed that she was dependent on staff for all efforts related to bed mobility, transfer, and toileting, requiring assistance from two or more helpers. Despite these documented needs, the activity staff member who returned the resident to her room did not notify the nursing staff, leaving the resident alone and unsupervised. Interviews with facility staff, including the MDS coordinator, RN, CNA, and DON, confirmed that the resident required assistance and should not have been left alone. The facility's policy on managing fall risks emphasized the need for prioritizing interventions based on resident fall risks, which was not adhered to in this case. The incident resulted in the resident being transferred to the hospital for treatment of the laceration, where she received 18 stitches.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nurses and nurse aides were adequately trained and demonstrated competency in testing the functionality of Wander Management Transmitters for nine residents. These devices, known as wander guards, are crucial for preventing resident elopement by alerting staff if a resident attempts to leave the facility. The deficiency was identified through observations, interviews, and record reviews, revealing that staff were not using the appropriate method to test the functionality of the wander guards, as outlined in the facility's policy and the Wander Management Transmitters User Guide. Several staff members, including licensed vocational nurses and registered nurses, were interviewed and demonstrated a lack of knowledge regarding the proper testing procedures for the wander guards. Some staff members believed that bringing residents to the exit doors to test the devices was sufficient, while others were unaware of the existence of a transmitter tester device. The Director of Staff Development admitted to not providing training on the use of the wander guard tester, and the Director of Nursing confirmed that the correct procedure involved using a transmitter tester, not taking residents to the doors. The report highlighted that the facility's policy and the Wander Management Transmitters User Guide clearly stated the need for adequate training and the use of a transmitter tester to verify the functionality of the devices. The failure to follow these guidelines and ensure proper training and testing procedures put residents at risk of elopement due to potential system failure. The deficiency was evident across multiple shifts, with staff members from both day and night shifts displaying inconsistent and incorrect practices regarding the testing of wander guards.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident. Upon admission, the resident did not have any wounds or skin integrity concerns, and their Braden Scale score indicated they were at risk for developing pressure sores. However, during their stay, the facility staff did not identify or document any skin issues or pressure ulcers, and no nursing interventions were implemented to aid in wound healing. When the resident was transferred to a hospital, an unstageable pressure injury to the coccyx and a deep tissue pressure injury to the left ankle were identified. The deficiency was further compounded by the actions of LVN A, who completed the Daily Skilled Charting Forms remotely and did not physically assess the resident. LVN A based her documentation on previous progress notes from other healthcare professionals, which is against professional standards of practice. The facility's human resources/payroll manager confirmed that LVN A worked remotely and did not have a signed job description for her role as a regional MDS nurse. Interviews with the director of nursing and other staff members revealed that physical assessments, including documentation for Daily Skilled Charting, should be conducted while present in the facility. The facility's policy on charting and documentation emphasized the need for objective, complete, and accurate documentation of services provided to residents. The failure to adhere to these standards resulted in the resident not receiving necessary pressure ulcer treatment and nursing interventions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that care and services were provided in accordance with professional standards of practice for three residents. For Resident 1, the Daily Skilled Charting documentation was completed by an LVN working remotely, without physically assessing the resident. This documentation inaccurately summarized the assessment and care provided, failing to identify pressure ulcers and lacking a care plan for urinary catheter use. Additionally, laboratory tests ordered by the physician were not completed, which contributed to Resident 1 being transferred to the hospital with septic shock, UTI, and pneumonia. Resident 2's Daily Skilled Charting documentation was also completed remotely by LVNs without physical assessment. The documentation failed to accurately describe the resident's condition, omitting details about a pressure ulcer and its treatment. The LVNs based their documentation on previous progress notes rather than direct assessment, leading to incomplete and inaccurate records of the resident's medical condition and care. Similarly, Resident 3's documentation was completed remotely by LVNs, who did not perform physical assessments. The documentation did not reflect the resident's use of an indwelling catheter, which was part of the resident's care plan. The DON confirmed that the documentation should have included this information, highlighting a consistent issue with remote documentation practices that did not meet professional standards of care.