Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Santa Fe Heights Healthcare Center, Llc during CMS and state inspections, most recent first.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
Failure to Provide and Document Ordered Restorative Nursing and ROM Services: The facility did not ensure ordered restorative nursing and ROM services were carried out for multiple residents with impaired mobility, contractures, and ADL dependence. A resident on hospice did not have a care plan addressing ROM limitations despite severe joint restrictions and wanting ROM exercises. Another resident did not receive ordered splinting and hand rolls as prescribed, and RNA staff did not notify the charge nurse when the splint could not be tolerated. A third resident was repeatedly observed without ordered PRAFO boots, and RNA staff stated the boots were not applied as ordered. A fourth resident had refusals and passive participation with ordered sit-to-stand RNA therapy, but rehab and nursing were not notified.
Restorative nursing documentation was inaccurate and incomplete for several residents. RNA records showed ambulation, ROM, splinting, and boot use that staff later said were not actually provided as documented, while another resident’s records did not show repositioning or bathing despite a care plan for q2h repositioning and high pressure injury risk. The DSD stated the documentation could not verify the care was provided.
A facility failed to timely refer a resident with Alzheimer's disease, severely impaired cognition, and fluctuating then absent decision-making capacity to OLTCPR. The resident had no family or friends involved in care, and the bio-ethics committee served as the responsible party and consented to medical treatments for an extended period. The QA Nurse and DON stated the referral should have been made as soon as possible after admission or after the decline in capacity was identified.
A resident with dementia and bipolar disorder, and documented as lacking capacity to consent, was given psychotropic medications after the physician obtained consent from the resident instead of the RP. The record identified the RP as the surrogate decision maker, and RN and DON interviews confirmed the resident should not have been the consenting party because of severely impaired cognition and inability to understand the risks and side effects of the medications.
Call lights were not kept within reach for three residents with significant cognitive and functional impairments. One resident with contractures had the call light pinned near his shoulder and could not easily grab it, another resident's call light was found on the floor behind the bed, and a third resident's call light was on the floor behind the curtain. Care plans for each resident directed staff to keep the call light within reach, and staff interviews confirmed the devices were not positioned appropriately.
Advance directive and POLST forms were not properly reviewed or completed for two residents. One resident had an incomplete POLST lacking required signatures and no signed advance directive acknowledgment, despite records showing impaired decision-making and an H&P stating he lacked capacity. Another resident with dementia and severely impaired cognition signed both the advance directive acknowledgment and POLST even though the H&P and SSD stated she lacked capacity and her RP was the medical decision-maker.
A resident with paraplegia, dysphagia, dementia, and a hx of falls was observed in bed with the bed placed against the wall and both upper side rails raised. An LVN stated this was being used as an ongoing fall-prevention measure and that it limited the resident’s ability to get out of bed. The record review found no evidence that less restrictive interventions had been tried, and there was no MD order or informed consent for the restraint.
Failure to develop individualized care plans for several residents left key needs unaddressed. A resident with palliative needs and ROM limitations had no plan for comfort-focused mobility or ROM interventions; a resident receiving Apixaban had no anticoagulant care plan despite an order to monitor for side effects; a resident with hearing impairment and hearing aids had no plan for communication or hearing aid use; and a resident with bilateral bed grab bars had no plan addressing their use or related safety concerns.
Failure to Provide Nail Care and Grooming: A resident with DM, CKD, dementia, and a left BKA had severely impaired cognition and required assistance with personal hygiene and grooming. The resident was observed with overgrown, jagged fingernails with discoloration and debris, while CNA and LVN interviews and record review showed no documentation of nail-care refusal during the reviewed period, despite staff stating the resident often refused grooming and that nail care was part of CNA duties.
Failure to Initiate Ordered PT and OT Services: A resident with hemiplegia, hemiparesis, COPD, and depression had a physician order for PT and OT to address impaired mobility and ADL dependence, but the EMR contained no therapy evals, treatment notes, or documentation that referrals were sent. The resident said she had not been seen by therapy since last year, wanted to get stronger and walk better, and felt weaker and more dependent, while nursing and rehab staff stated the orders were not initiated and the therapy dept never received the referral.
Failure to Follow Up on Hearing and Vision Referrals: The facility did not complete follow-up on audiology and optometry referrals for two residents. One resident with dementia and hearing difficulty had ENT-documented diminished hearing, but his hearing aids were not serviced and he remained unable to hear clearly. Another resident with fractures and impaired cognition had an eye health/vision consult order for glasses, but the SSD did not follow up in a timely manner, delaying access to glasses and leaving the resident unable to read as before.
A resident with an indwelling urinary catheter, dementia, urine retention, COPD, and a history of catheter-related infection was observed self-propelling his wheelchair while the catheter drainage bag dragged on the pavement and floor. The resident’s care plan directed staff to keep all tubing suspended off the floor, and the facility policy required the catheter tubing and drainage bag to be kept off the floor. An LVN observed the bag attached beneath the wheelchair low enough to rest on the floor and stated this could lead to accidental catheter removal, urethral trauma, and UTI.
Oxygen therapy was not provided per order for two residents. One resident with COPD and respiratory failure was observed receiving oxygen at a higher flow rate than ordered, while another resident with COPD, acute respiratory failure, OSA, and morbid obesity with hypoventilation was observed on continuous oxygen without dated tubing, without a humidifier, and without oxygen-in-use signage posted. Staff stated the tubing should be dated, a humidifier was needed, and signage was required for safety.
Improper Side Rail Assessment, Order, and Consent: The facility failed to complete an accurate bed rail assessment and, for one resident, failed to obtain a provider order and verify informed consent before bilateral side rails were used. One resident had severely impaired cognition, lacked capacity to consent, and was observed with grab bars on the bed despite no indication on the assessment, no order, and no documented RP consent. Another resident with dementia and stroke-related deficits was observed with bilateral side rails used for bed mobility, but the assessment did not reflect the current use or family request.
An LVN failed to explain medications to one resident before giving them and pre-poured medications for another resident, leaving a labeled medication cup in the cart drawer until later administration. Surveyors observed the LVN preparing meds for more than one resident at the same time and storing a pre-prepared cup in the cart, contrary to facility policy requiring meds to be given when prepared and by the same person who prepared them. The affected residents had significant psychiatric diagnoses and severely impaired cognition, and one resident’s rights to be informed of treatment were not followed.
A resident with dementia and bipolar disorder was ordered divalproex sodium for erratic mood swings, and the care plan directed staff to monitor for side effects every shift and notify the physician if any were present. However, the active orders did not include monitoring for side effects, and the RN and DON acknowledged that monitoring was needed for this psychotropic medication.
Medication pass errors resulted in a 5.71% error rate when an LPN did not tell a resident what medications were being given or their purpose and pre-prepared another resident’s meds, storing them in the med cart before administration. One resident had DM, schizophrenia, depression, dysphagia, and CKD, while the other had DM, schizophrenia, depression, hypertensive heart disease, and bipolar disorder; both had severely impaired cognition. The facility policy required meds to be administered when prepared, not pre-poured, and residents to be informed of their care.
Fortified Diet Orders Not Followed During Lunch Service: A dietary worker did not communicate fortified diet orders on meal tickets during tray line, and the food server did not add the ordered fortified items for residents on fortified diets. Staff later stated they relied on each other to identify fortified trays, and the DS confirmed the facility did not ensure the ordered fortified modifications were provided per policy.
Arbitration Agreement Signed by Resident Without Capacity: A resident with dementia and bipolar disorder was documented as severely impaired in daily decision making and had an RP listed as surrogate decision maker, yet she personally signed a binding arbitration agreement waiving the right to court trial. Staff later acknowledged the agreement should have been reviewed with the RP because the resident lacked capacity to consent.
Improper Storage of Outside Food at Bedside: A resident with DM, CKD, left BKA, and severely impaired cognition had outside food left unrefrigerated on a bedside table, including a container of food and pizza boxes. The resident said a family member brought the food the day before. Staff stated outside food should be labeled and refrigerated within one hour if kept, and the facility policy required prepared food from outside sources to be consumed within one hour or stored in a refrigerator.
A resident with epilepsy, TBI, cognitive impairment, and a history of falls had a call light that was missing its push button and did not work. The resident stated the call light did not work, and a CNA confirmed it was non-operational and that staff would not know if the resident needed help or had an emergency. The MSA said he was responsible for repairing broken call lights, but he had not been notified and the issue was not documented in the maintenance log.
Failure to monitor a resident and maintain ordered fall mats: A resident with schizophrenia, heart disease, COPD, suicidal ideations, and impaired cognition was not visually monitored as expected, exit alarms were not documented as armed, and he left the facility undetected before being found at a GACH about 9.5 miles away. A second resident with paraplegia, dementia, and a fall history had an order and care plan for bilateral floor mats, but staff observed only one mat beside the bed while an LPN confirmed both sides were required.
Insufficient Room Space in Multiple Resident Rooms: The facility failed to provide at least 80 sq. ft. per resident in 22 of 39 rooms. A review of the room waiver request identified Rooms 11, 12, 14, 15, 17, 18, and 21 through 36 as not meeting the requirement. The ADM stated there were no complaints and that the rooms had enough space for Hoyer lifts, wheelchairs, and gurneys to operate, while survey observations found no adverse effects related to resident care, privacy, health, or safety.
A resident with PVD, PTSD, and major depressive disorder, who had decision-making capacity and no documented behavioral symptoms on a recent MDS, was hospitalized and later medically cleared by a GACH to return. Instead of following its usual process of obtaining and reviewing clinical documents for the DON or designee to determine if the resident’s needs could be met, the facility—through the MD and DON—denied readmission based on prior alleged aggressive behavior, without receiving or reviewing current clinical records. Staff interviews confirmed that aggressive behavior was not an accepted reason to refuse readmission, that no clinical documents were obtained, and that multiple beds, including male beds, were available. Facility policies required allowing return to an available bed and obtaining appropriate medical records prior to or upon admission, but these were not followed, leading to the resident’s unnecessary extended stay in the hospital.
A resident with PTSD, major depressive disorder, and known aggressive behavior had an IDT meeting where the team identified verbal aggression toward staff and recommended ongoing monitoring of behavioral symptoms. The existing behavioral care plan listed aggressive behavior, verbal abuse, and sudden angry outbursts but did not include any intervention to monitor these behaviors, and no corresponding orders for behavior monitoring were in place to prompt shift-by-shift documentation. Nursing staff, including an LVN and an RN, acknowledged that the care plan should have been updated and that an order for behavior monitoring was needed so licensed nurses could track behavior frequency and inform the physician, consistent with facility policies requiring ongoing assessment and revision of care plans for behavioral symptoms.
A resident with dementia, osteoporosis, prior falls, impaired balance, and lower extremity impairment was care planned as a high fall risk and placed on a Falling Star Program requiring closer monitoring, environmental precautions, and documented visual checks. Despite this, nursing notes and ADL flowsheets showed no documented monitoring or visual checks before an unwitnessed fall in the resident’s room, where no floor mat was present and the resident later reported rolling out of bed, resulting in a skin tear and an acute pelvic fracture. Staff interviews revealed that CNAs and an LVN relied on informal monitoring without documentation, some were unaware of the resident’s fall-risk status, and the required Falling Star identifier and visual observation logs were not in place, contrary to facility policies requiring monitoring and documentation of fall-prevention interventions.
A resident with PTSD, major depressive disorder, and documented decision-making capacity developed agitation, verbal aggression, and sudden angry outbursts. An SBAR and subsequent care plans identified these behavioral symptoms and included an intervention for a psychological evaluation, and the IDT recommended a referral to psychology. However, no referral was made, no psychology note was found in the chart, and the consulting psychologist reported not being informed of the behavioral change. Staff stated that without the recommended psychological evaluation, the resident was at risk for psychological distress, poor coping skills, and continuation of aggressive behavior.
Licensed nursing staff administered psychotropic medications to a resident with cognitive impairment and mental health diagnoses before obtaining the required informed consent, as confirmed by record review and staff interview. The facility's policy required written informed consent prior to starting such medications, but the consent was obtained only after the medications had already been given.
Licensed nursing staff did not update the fall care plan for a resident with cognitive impairment and psychiatric diagnoses after multiple falls. Despite repeated incidents, no new interventions were developed, and staff interviews confirmed that care plans were not revised as required by facility policy, leaving the resident without effective fall prevention measures.
A resident with multiple comorbidities experienced a fall and subsequently developed new shoulder pain and limited mobility, which was observed by CNAs but not effectively communicated to the LVN or documented using the required Stop and Watch form. An LVN later noted skin redness but did not document or report it. These failures led to a delay in physician notification and the discovery of a clavicle fracture and significant bruising several days after the fall.
A resident with multiple neurological and cognitive impairments suffered an unwitnessed fall and was initially assessed by an LVN, who documented a head hematoma. Facility policy required the RN supervisor to complete the post-fall incident report and conduct a thorough assessment, but this was not done. The RN supervisor was unaware of the policy and did not perform the required assessment, resulting in a missed clavicle fracture that was only identified seven days later after the resident reported shoulder pain.
A resident with a history of schizophrenia and mood disorder exhibited ongoing erratic mood swings, auditory hallucinations, and aggressive behaviors that were not adequately monitored or addressed by staff. The facility failed to implement its abuse prevention policy, did not develop a care plan for schizophrenia, and did not document interventions for the resident's behaviors. This led to the resident physically assaulting another resident, resulting in injury and emotional distress.
A resident with schizoaffective disorder, bipolar disorder, and moderate cognitive impairment, who had a history of elopement, was able to leave the facility unsupervised after removing her wander guard bracelet. The care plan required frequent visual checks but did not specify intervals or documentation, leading to unclear supervision practices. Staff interviews confirmed the lack of clarity in monitoring procedures, which contributed to the resident's unsupervised departure.
A resident with a history of hypertensive heart disease and other conditions received antihypertensive medications without required assessment or documentation of blood pressure and pulse prior to administration, as ordered by the physician and indicated in the care plan. The failure occurred due to an LVN not entering supplemental documentation fields in the eMAR, resulting in no recorded vital signs before medication administration on several occasions.
The facility failed to ensure staff were knowledgeable about the policy for storing food brought by visitors, risking bacterial growth and cross-contamination for 88 residents. Interviews revealed staff confusion about food storage procedures, with some unaware of designated storage areas and policy details. The Dietary Supervisor and LVNs showed limited understanding, while the QA Nurse stressed the importance of policy awareness for food safety.
The facility failed to ensure proper infection control practices, as a housekeeper did not perform hand hygiene after cleaning a resident's room, and a nurse did not sanitize a contaminated surface. Additionally, a resident's nebulizer equipment was improperly stored on the floor, increasing the risk of infection.
The facility failed to ensure proper storage and labeling of medications, including storing a food item with medications, not removing expired medications, and using an unapproved container for G-tube flushes. Additionally, several medications were either expired, improperly stored, or lacked proper labeling, affecting multiple residents. Controlled medications for discharged residents or discontinued orders were not removed or documented properly, posing risks of misuse.
The facility failed to ensure kitchen staff were properly trained and evaluated for competency in food safety procedures, particularly in operating dishwashing equipment and using sanitizing solutions. Dietary Aides were unable to correctly state the acceptable temperature and chlorine concentration for the dishmachine, and the facility's competency checklists did not include verification for these tasks. Additionally, staff did not follow manufacturer's guidelines for testing QUAT sanitizer concentration, posing a risk of unsanitized dishes and potential foodborne illnesses for 87 medically compromised residents.
The facility failed to serve correct portion sizes to residents, with 75 residents on a regular diet receiving 1/3 cup instead of 1/2 cup of sweet corn salad, and four residents on a renal diet receiving less wheat pasta due to incorrect utensil use. This could lead to inadequate nutrition and unintended weight loss.
The facility failed to maintain food quality and temperature, serving sweet corn salad at 62°F and overcooked, unseasoned broccoli. Two residents, including one with malnutrition, expressed dissatisfaction with the food's taste and appearance. The Dietary Supervisor and RD acknowledged the issues, noting improper handling and serving of meals, potentially affecting residents' nutritional intake.
The facility failed to prepare pureed foods to IDDSI Level 4 standards, as observed with the pureed Cajun country rice, which was sticky and did not hold its shape. The Dietary Supervisor confirmed the inconsistency, and the Registered Dietitian noted that IDDSI diets were not implemented due to lack of training. This affected 8 residents on a pureed diet, posing risks of swallowing difficulties and unintended weight loss.
The facility exhibited multiple deficiencies in food safety and sanitation, including unclean kitchen equipment, improper storage of wet pans and dented cans, and inadequate handwashing by staff. Equipment was not maintained in a condition that prevents bacterial growth, with chipped can openers, cracked trays, and rusted scoop storage. Additionally, the freezer lacked a thermometer for temperature monitoring, and the emergency water storage area was not properly maintained.
The facility failed to honor the rights and dignity of two residents. A CNA was observed watching TV on her phone while feeding a resident, compromising safety and dignity. Additionally, the facility did not hold bioethics committee meetings or obtain public guardians for residents unable to make medical decisions, leading to the administration of psychotropic medications without proper consent.
The facility failed to obtain informed consent for psychotropic medications for two residents. One resident, with schizoaffective disorder, was given haloperidol without consent, despite lacking decision-making capacity. Another resident, with schizophrenia and severe cognitive impairment, had incomplete consent documentation for Risperdal and incorrect consent for haloperidol. The facility did not follow its policies requiring consent from a representative or bioethics committee involvement.
The facility failed to ensure call lights were within reach for two residents, potentially delaying necessary care. One resident with multiple health issues was observed with the call light out of reach, despite care plans emphasizing its importance for fall prevention. Another resident with severe cognitive impairment also had an inaccessible call light. Staff interviews confirmed the importance of call light accessibility, but observations showed non-compliance with facility policies.
A resident with epilepsy had subtherapeutic phenobarbital levels, but the facility failed to notify the physician, contrary to policy. The resident later experienced seizures, requiring emergency intervention. The RN and DON confirmed the oversight, which was against the facility's policy to report such lab results.
A facility failed to accurately code a resident's MDS regarding their dental status, resulting in incorrect data being sent to CMS. The resident, who had dentures, was incorrectly assessed as having no oral issues. This discrepancy was confirmed by the MDS Nurse, highlighting a deficiency in the facility's assessment process.
A facility failed to accurately complete the PASARR Level I screening for a resident, omitting diagnoses of depression and anxiety. The resident's Face Sheet and MDS indicated these active diagnoses, but the PASARR incorrectly stated no serious mental illness. The DON confirmed the error, highlighting the risk of the resident not receiving necessary specialized care.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Provide and Document Ordered Restorative Nursing and ROM Services
Penalty
Summary
The facility failed to ensure rehabilitation and restorative nursing services were provided as ordered for four sampled residents with limited range of motion and mobility needs. The report identified deficiencies involving Resident 11, Resident 28, Resident 16, and Resident 69, each of whom had diagnoses and assessments showing functional impairments, contractures, or dependence in activities of daily living. The facility did not carry out ordered restorative interventions, did not consistently document or provide the ordered services, and in some cases did not notify the appropriate departments when the ordered care could not be completed. Resident 11 had diagnoses including palliative care, cachexia, contracture of the left hand, and an unstageable sacral pressure ulcer. The MDS showed moderately impaired decision-making and functional ROM impairments in both upper and lower extremities, with substantial assistance needed for ADLs. The Joint Mobility Assessment documented severe and moderate ROM limitations in multiple joints, but the medical record did not show care plans addressing those ROM limitations. The PT stated Resident 11 was under hospice care and therefore did not receive a rehabilitation evaluation, and the facility practice was not to provide RNA services to residents under hospice care. Resident 11 and his representative both stated he wanted ROM exercises, and the PT stated gentle passive ROM could have benefited him. Resident 28 had diagnoses including adult failure to thrive, dysphagia, and hypertensive heart disease, with the MDS showing moderately impaired cognition, ROM limitations in the upper and lower extremities, and substantial assistance needed for ADLs. The care plan directed staff to carry out the RNA program as ordered, and the physician orders included right elbow splinting, bilateral lower extremity PROM, pain monitoring before splinting, bilateral upper extremity AAROM, and bilateral hand rolls. During repeated observations, the resident did not have the hand rolls or right arm splint in place and stated staff did not provide ROM exercises that day. RNA staff later stated the hand rolls were not applied as ordered, bandages were placed in the palms instead, the right elbow splint was not applied because the resident could not tolerate it, and the charge nurse was not notified. Resident 16 had diagnoses including polyneuropathy, a right femur fracture, contractures of both ankles, and muscle disorders. The MDS showed severe cognitive impairment, ROM limitations in the upper and lower extremities, and total dependence for ADLs. The physician orders required bilateral lower extremity gentle PROM, bilateral lower extremity PRAFO boots, and upper extremity AAROM. The resident was observed in bed without PRAFO boots on multiple occasions. RNA staff stated the boots were not applied as ordered and that the documentation for the RNA orders was unclear, even though the boots were ordered to maintain foot positioning and prevent further contractures and heel pressure ulcers. Resident 69 had diagnoses including spondylopathy, bilateral lower extremity amputations, and a T7-T8 wedge compression fracture. The MDS showed moderately impaired cognition, lower extremity impairment, and substantial assistance needed for multiple ADLs. The physician ordered RNA sit-to-stand activity with the left below-knee prosthesis only. The resident refused therapy on some days and only partially participated on others, but the RNA task flow sheet showed refusals and passive participation rather than completion of the ordered activity. RNA staff stated the resident did not want to complete the full sit-to-stand order and that the rehab and nursing departments should have been notified when the resident refused or did not complete the therapy. The DOR and DON both stated they were unaware of the refusals and passive participation and that the resident did not receive the full rehabilitation he required.
Restorative Nursing and Care Documentation Not Accurately Recorded
Penalty
Summary
The facility failed to ensure restorative nursing aides accurately documented care provided and failed to ensure repositioning and bathing were performed and documented for four sampled residents. The deficient practices involved Resident 16, Resident 28, Resident 65, and Resident 11, and resulted in clinical records that did not reliably reflect restorative nursing care provided to Residents 16, 28, and 65. The report states this affected the facility’s ability to monitor implementation of restorative nursing services and timely re-evaluate resident treatment needs. Resident 65 had diagnoses including spondylosis with radiculopathy, low back pain, intervertebral disc degeneration, and a history of falling. The resident’s MDS indicated moderately impaired cognitive skills for daily decision making and need for supervision with walking, toileting, showering, and putting on footwear. Although there was an order for RNA to ambulate the resident with a front wheeled walker five times a week or as tolerated, the resident stated on multiple observations that staff had not assisted him to walk or offered walking exercises. RNA documentation showed ambulation on days when the resident said it did not occur, and RNA 1 stated documentation was not entered when the service was rendered and could not explain the discrepancy. Resident 28 had diagnoses including adult failure to thrive, dysphagia, and hypertensive heart disease, with MDS findings of moderately impaired cognition, ROM limitations, and substantial assistance needed for ADLs. Orders included right elbow splinting, bilateral lower extremity PROM, pain monitoring, and bilateral upper extremity AAROM followed by bilateral hand rolls. During repeated observations, the resident did not have hand rolls applied and did not have the right elbow splint in place, and the resident stated staff did not apply hand rolls or provide ROM exercises that day. RNA documentation nevertheless recorded splinting and ROM services as completed, and RNA 1 stated she did not apply the hand rolls as ordered, used bandages in the resident’s palms instead, did not apply the elbow splint because the resident could not tolerate it, and that the documentation did not accurately reflect the services provided or the resident’s ability to tolerate the program. Resident 16 had diagnoses including polyneuropathy, a right femur fracture, bilateral ankle contractures, and muscle disorders, with MDS findings of severe cognitive impairment, ROM limitations, and total dependence for ADLs. Orders included bilateral lower extremity gentle PROM, bilateral PRAFO boots for four hours daily five days a week or as tolerated, and upper extremity active assist ROM. Observations showed the resident in bed and stated he did not have PRAFO boots. RNA documentation indicated the boots were applied and PROM was provided, but RNA 2 stated she did not apply the PRAFO boots and did not follow the physician orders. RNA 2 also stated there was no designated documentation field for PRAFO boot application and that the documentation for RNA orders was unclear. Resident 11 had diagnoses including palliative care, cachexia, left hand contracture, and an unstageable sacral pressure ulcer. The resident’s MDS showed moderately impaired cognition, ROM impairments in both upper and lower extremities, and substantial assistance needed for ADLs. The care plan directed repositioning as needed and every two hours, and the Braden assessment identified the resident as high risk for pressure injury. Review of the task flow sheets did not show that the resident was repositioned or bathed, and the DSD stated the facility could not verify repositioning was provided because there was no documentation and could not verify when the resident was last bathed.
Delayed Referral for Public Patient Representative
Penalty
Summary
The facility failed to timely submit a referral to the Office of the Long-Term Care Patient Representative (OLTCPR) for one sampled resident, Resident 25. Resident 25 was admitted and later readmitted to the facility with diagnoses including Alzheimer's Disease, senile degeneration of the brain, and major depressive disorder. The admission record identified the facility's bio-ethics committee as the resident's responsible party, and the resident's MDS showed severely impaired cognition and need for maximal assistance with oral hygiene, toileting, bathing, dressing, and personal hygiene. Resident 25's H&P documented fluctuating capacity to understand and make decisions, and a later H&P stated the resident did not have the capacity to understand and make decisions. During interview, the QA Nurse stated that when a resident has fluctuating capacity and no family or friends, the bio-ethics committee oversees the resident's care and acts as the responsible party for consent, but that this should only be a short-term solution and the resident should be referred to OLTCPR as soon as possible. The QA Nurse also stated that Resident 25 had been overseen by the bio-ethics committee for as long as she could remember. The QA Nurse and DON stated Resident 25 met the requirements for a public patient representative and should have been referred earlier, because the resident had no family or friends involved in care and had received medical treatments requiring informed consent. The progress note indicated the resident could make basic needs known and would be referred to OLTCPR for medical interventions requiring informed consents, but the QA Nurse stated the referral should have been submitted earlier than it was. The DON stated the delayed referral resulted in the bio-ethics committee overseeing the resident's care and consenting to medical treatments, rather than a timely assignment of a representative.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from Resident 10’s responsible party before administering psychotropic medications. Resident 10 was admitted with diagnoses including dementia and bipolar disorder, and the record showed she had severely impaired cognition on the MDS and did not have the capacity to consent per the H&P. Her admission record identified Responsible Party 2 as her decision maker, and the hospital psychosocial assessment also identified RP 2 as her primary surrogate decision maker. The physician obtained informed consent for Divalproex Sodium and Quetiapine from Resident 10, and the facility’s Verification of Informed Consent form reflected that Resident 10 herself provided consent. During interview, RN 1 stated Resident 10 should not have consented because she lacked capacity and had an appointed surrogate decision maker. The DON stated informed consent for psychotropic medication had to be obtained from the resident if capable, or from the responsible party if not, and acknowledged Resident 10 did not have the capacity to consent. The facility policy stated that if the resident is not capable of giving informed consent, consent will be obtained from the resident’s representative.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for three sampled residents. Resident 28 was admitted and readmitted to the facility with diagnoses including adult failure to thrive, dysphagia, and hypertensive heart disease. His MDS indicated moderately impaired cognition, functional ROM limitations to the upper and lower extremities, and substantial assistance needed for ADLs. His care plan for fall risk directed staff to keep the call light within reach and answer promptly, yet during multiple observations the call light was pinned near his right shoulder and was not within functional reach. During a concurrent observation and interview, Resident 28 stated it was hard to grab the call light, and an LVN stated it was not in reach and was not an appropriate device because of severe contractures of both upper extremities. Resident 91 was admitted and readmitted to the facility with diagnoses including Parkinson's disease, Alzheimer's disease, schizoaffective disorder, epilepsy, and anxiety. His MDS indicated severely impaired cognition and a need for supervision or touching assistance with ADLs. His care plan for risk for falls included ensuring the call light was placed within reach and answered promptly. During several observations in the resident's room, the call light was found on the floor behind the bed and was out of reach. Resident 48 was admitted to the facility with diagnoses including Parkinson's disease, schizoaffective disorder, and anxiety. His MDS indicated moderately impaired cognition and maximum assistance needed for ADLs. His care plan for behavioral patterns of restlessness included ensuring the call light was placed within reach. During observation, the resident was lying in bed while the call light was on the floor behind the curtain and not within reach. During a concurrent observation and interview, a CNA stated the call light was on the floor and not within reach, and an RN stated the call light must be placed within the resident's reach at the bedside and that licensed staff were responsible for ensuring call lights were checked and positioned within reach.
Advance directive and POLST forms not reviewed or completed with appropriate decision-makers
Penalty
Summary
The facility failed to ensure that two residents’ POLST forms and advance directive rights were reviewed, completed, and accurately reflected their wishes. For one resident, the admission record showed diagnoses including palliative care, cachexia, contracture of the left hand, and an unstageable sacral pressure ulcer. The MDS indicated moderately impaired cognitive skills for daily decision making and substantial assistance with ADLs, and the H&P stated the resident did not have the capacity to understand and make decisions. Despite this, the resident’s POLST dated 1/1/2026 was incomplete, lacked physician and witness signatures, and indicated DNR with the resident’s signature. The SSD stated the form was incomplete and invalid, and the resident’s medical record also lacked a signed advance directive acknowledgment form. During interviews, the resident stated he could make decisions for himself but wanted to consult his brother, and he stated he wished for chest compressions if found unresponsive. RN 1 stated that if the resident wanted chest compressions, he would need to be considered full code. The SSD stated the advance directive acknowledgment form was usually completed during admission to review code status, treatment, and end-of-life preferences, but it was missed. The SSD also stated that if the POLST had been reviewed, the resident or his brother would have completed it so it accurately reflected the resident’s end-of-life wishes and included the required signatures. For the second resident, the admission record showed diagnoses of dementia and bipolar disorder, and the MDS indicated severely impaired cognition. The H&P stated the resident did not have the capacity to consent. The SSD stated she was responsible for reviewing advance directive acknowledgment and POLST forms with the resident or responsible party upon admission and reviewing hospital records to determine whether the resident had the mental capacity to understand the forms. The hospital psychosocial assessment identified the responsible party as the primary surrogate decision maker, and the SSD stated that person was the resident’s decision maker for medical decisions. However, the advance directive acknowledgment form was completed with the resident’s signature and stated she understood her rights to accept or refuse treatment and to formulate an advance directive, and the POLST was also signed by the resident indicating consent to resuscitation and full treatment. The SSD and DON both stated the resident did not have the mental capacity to complete those forms and that they should have been reviewed with the responsible party instead.
Unnecessary Physical Restraint Used for Fall Prevention
Penalty
Summary
The facility failed to ensure that one sampled resident was free from an unnecessary physical restraint when the resident’s bed was placed directly against the wall with both upper side rails raised. Resident 4 was admitted and later readmitted to the facility with diagnoses including paraplegia, dysphagia, dementia, and a history of falls. The resident’s MDS dated 2/4/2026 indicated moderately impaired cognition and maximum assistance needed for activities of daily living. During observations on 2/2/2026, Resident 4 was seen lying in bed with the bed positioned against the wall on the left side and both upper side rails raised. During interview on 2/5/2026, LVN 1 stated the bed was placed against the wall and the side rails were kept up as ongoing fall-prevention measures, and that this limited Resident 4’s ability to get out of bed and prevented her from falling. LVN 1 also stated there was no documented evidence that less restrictive interventions had been attempted, and there was no physician order or informed consent for the use of physical restraint. The facility policy stated restraints were only to be used after other alternatives had been tried unsuccessfully, not for fall prevention, and only with a physician order and consent.
Failure to Develop Individualized Care Plans for Mobility, Anticoagulant Use, Hearing Impairment, and Bed Grab Bars
Penalty
Summary
The facility failed to develop individualized care plans for four sampled residents when their assessed needs were not reflected in the care planning process. Resident 11 was admitted with palliative care needs, cachexia, a left hand contracture, and an unstageable sacral pressure ulcer. The Joint Mobility Assessment dated 1/6/2026 documented severe limitations in both shoulders, moderate limitations in multiple other joints, and moderate to severe limitation of the left wrist, but the assessment did not include recommendations or interventions to address range of motion needs. Review of the resident’s care plans showed no plan to address the ROM impairments or comfort-focused mobility interventions, and the MDS Nurse stated there was no care plan for those limitations. Resident 3 had diagnoses including acute embolism and thrombosis of the right popliteal vein, myocardial infarction, kidney disease, anemia, and a history of falling. The resident’s records showed fluctuating capacity to understand and make decisions, severe cognitive impairment on the MDS, and active anticoagulant therapy with Apixaban ordered for DVT prophylaxis. A physician order also directed staff to observe closely for significant side effects of anticoagulant medications. During interview, LVN 3 stated there was no care plan for the anticoagulant and that a resident receiving anticoagulant therapy would require monitoring for signs of bleeding, instructions on when to hold the medication, and when to notify the physician. Resident 57 had dementia, depression, and anxiety disorder, with intact cognition on the MDS and moderate difficulty hearing. The resident had hearing aids, but during observation they were stored in a case on the nightstand, and the resident stated they were not helpful because outside noise was amplified and speech was not clear. Review of the active care plans showed no plan to address hearing impairment or hearing aid use. The MDS Nurse and DON both stated a care plan should have addressed communication methods, hearing aid use, and assessment of whether audiology referral was needed. Resident 10 had dementia and bipolar disorder, severe cognitive impairment on the MDS, and required moderate assistance with toileting, bathing, and footwear. Although bilateral grab bars were present on the bed, there were no physician orders indicating their use and no care plan addressing the grab bars. RN 1 stated the grab bars could present safety concerns such as entrapment and injury, and the DON stated there was no documentation detailing their use or the interventions staff had to implement to ensure safety.
Failure to Provide Nail Care and Grooming
Penalty
Summary
The facility failed to ensure that one sampled resident received nail care and grooming services. Resident 53 was admitted with diagnoses including DM, left BKA, CKD, osteoarthritis, dementia, and anxiety disorder. The H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated severely impaired cognition, independence with eating, and moderate assistance needed for toileting, bathing, dressing, and personal hygiene. The care plan for ADLs and functional mobility, initiated 12/18/2024, identified that Resident 53 required assistance with personal hygiene and grooming, with the goal of grooming and meeting daily needs and interventions to assist with ADLs as needed and monitor for ADL needs. During observation on 2/2/2026, Resident 53 was lying in bed, alert and awake, with fingernails that were overgrown, jagged, and uneven, extending beyond the fingertips, with yellow discoloration and dark debris visible beneath several nails. CNA 5 stated the resident's nails were dirty and untrimmed and that nursing staff made sure residents' nails were clean and trimmed every day. LVN 5 reviewed progress notes from 1/31/2026 to 2/3/2026 and stated there was no documentation of refusal of fingernail grooming during that period, although LVN 5 said Resident 53 often refused grooming and that refusals should have been reported and documented. The facility's ADL policy stated residents unable to carry out ADLs independently would receive grooming and personal hygiene services, and the CNA job description included assisting with nail care.
Failure to Initiate Ordered PT and OT Services
Penalty
Summary
The facility failed to implement physician-ordered PT and OT services for Resident 12. Resident 12 was admitted with diagnoses including hemiplegia, hemiparesis, COPD, and major depressive disorder. The H&P indicated she had capacity to make medical decisions, and the MDS indicated her cognitive skills for daily decision making were intact. The MDS also showed she required maximum assistance from staff for ADLs. A physician order dated 1/10/2026 directed a referral for PT and OT to address impaired mobility and ADL dependence. During interview, Resident 12 stated she had not been seen by PT or OT since last year and wanted therapy to get stronger and improve her ability to walk. She stated she spent most of the day in bed and felt weaker and more dependent since admission. Record review and staff interviews showed there were no PT or OT evaluation notes or treatment notes in the EMR after the order, no documentation that the referrals had been sent, no documented therapy services provided, and no documentation that Resident 12 refused therapy. Staff stated the orders had not been initiated, the therapy department had not received a referral or communication, and the licensed nursing staff were responsible for reviewing orders, notifying rehab, and following up to ensure services were started.
Failure to Follow Up on Hearing and Vision Referrals
Penalty
Summary
The facility failed to follow up on referrals for vision and hearing services for two residents. Resident 57 was admitted with diagnoses including dementia, depression, and anxiety disorder, and his MDS indicated intact cognition, need for setup or clean-up assistance with several ADLs, and moderate hearing difficulty. His H&P stated he had the capacity to understand and make decisions. A physician order dated 9/26/2025 included audiology consultation as needed for hearing problems. Resident 57 was seen by ENT on 9/29/2025, where diminished hearing was noted. The ENT documented that he had working hearing aids but had difficulty using them and recommended an audiogram and servicing for the hearing aids. During observation on 2/2/2026, Resident 57 had two hearing aids stored in a case on his nightstand and stated they were no good to him. He reported that outside noise was amplified and he could not hear other people clearly. The Audiology Manager stated the referral had been inaccurately inputted because of a clerical error at the audiology office, and the resident did not receive the audiogram or hearing aid service. The SSD stated the referral was not completed and that the facility should have followed up with the audiology office. Resident 42 was admitted with diagnoses including left femur fracture, right clavicle fracture, traumatic shock, motor vehicle accident, and lack of coordination. His MDS indicated moderately impaired cognitive skills for daily decision making and need for setup assistance with ADLs, while his H&P stated he had the capacity to understand and make decisions. An order summary dated 1/1/2026 directed the facility to ensure an eye health and vision consult with follow-up treatment as indicated. Resident 42 stated he had repeatedly asked for an update about his glasses and could not enjoy reading his books without them. The SSD reviewed an ophthalmology referral for optometry for glasses dated 12/23/2025 and stated she did not follow up until the week of the interview. The SSD stated timely follow-up was necessary to avoid delays in obtaining glasses, and the facility's social services job description identified coordination of optometry, dental, and audiology support services as part of the role.
Catheter drainage bag dragged on floor during wheelchair use
Penalty
Summary
The facility failed to implement its policy and procedure titled, Catheter Care Urinary, by not ensuring a resident’s indwelling catheter drainage bag was maintained off contaminated surfaces during wheelchair mobility. Resident 2 was admitted with diagnoses including COPD, acute respiratory failure, infection and inflammatory reaction due to an indwelling catheter, urine retention, and dementia. The resident’s MDS indicated severely impaired cognitive skills for daily decision making, dependence on staff for toileting and showering, and substantial assistance with ADLs. The H&P also noted fluctuating capacity to understand and make decisions. Resident 2’s care plan for the Foley catheter, initiated on 11/11/2025, directed staff to keep all tubing suspended without touching the floor and to provide catheter care each shift. Despite this, a progress note dated 11/30/2025 documented that the resident’s indwelling urinary catheter dislodged and caused penile trauma with continuous bleeding. During observations on 2/4/2026, the resident was seen self-propelling his wheelchair in the smoking patio and hallway while the catheter drainage bag dragged on the pavement and floor. During a concurrent observation and interview, LVN 1 observed the drainage bag attached beneath the wheelchair low enough to rest on the floor and stated it was important to keep the tubing and drainage bag off the floor to prevent accidental catheter removal, urethral trauma, and UTI. The facility policy stated the catheter tubing and drainage bag were to be kept off the floor.
Oxygen Therapy Not Provided Per Orders
Penalty
Summary
Oxygen therapy was not provided in accordance with physician orders and the facility's oxygen administration policy for two residents. One resident with COPD, acute respiratory failure, infection related to an indwelling catheter, urinary retention, and dementia was admitted with severely impaired cognitive skills and dependence on staff for toileting and showering. The resident's order summary indicated oxygen at 2 liters per minute via nasal cannula as needed, and the care plan directed staff to provide oxygen as ordered. During observation, the resident was receiving oxygen at 5 liters per minute via nasal cannula connected to an oxygen concentrator, and the resident was groggy and confused. RN 1 reviewed the order and photo of the resident receiving 5 liters per minute and stated this did not align with the physician's order. A second resident with COPD, acute respiratory failure, OSA, and morbid obesity with hypoventilation was admitted with diagnoses requiring continuous oxygen therapy. The resident's care plan directed staff to check and fill the humidifier every shift and change tubing weekly or as needed, and the order summary indicated continuous oxygen via nasal cannula. During observation, the resident was awake and alert in bed receiving oxygen at 3.5 liters per minute via nasal cannula. The oxygen tubing was not labeled or dated, there was no humidifier observed, and no oxygen-in-use signage was posted outside the doorway. During interview, LVN 4 stated the tubing should be dated and changed every Sunday, and that oxygen signage should have been posted outside the room. RN 1 stated residents receiving oxygen required a concentrator, tubing, humidifier, doctor's order, oxygen signage, and oxygen monitoring every shift. RN 1 also stated the tubing should have been labeled and dated for infection control purposes, that a humidifier was important because oxygen had a drying effect, and that oxygen signage was important because oxygen was combustible. RN 1 stated the admitting nurse was responsible for ensuring the resident's oxygen was labeled, a humidifier was provided, signage was posted, and the doctor's orders were followed upon admission.
Improper Side Rail Assessment, Order, and Consent
Penalty
Summary
The facility failed to follow its process for proper use of side rails for two residents by not completing an accurate bed rail assessment, not obtaining a physician order for one resident’s side rails, and not verifying informed consent before one resident’s side rails were used. The report states that these deficiencies involved Residents 10 and 62 and were identified through observation, interview, and record review. The facility policy required assessment of safety risk, discussion of risks and benefits with the resident or representative, informed consent, and correct installation and maintenance before bed rails were used. Resident 10 was admitted with dementia and bipolar disorder, had severely impaired cognition on the MDS, and was documented in the H&P as lacking capacity to consent. During observation, Resident 10 was seen sitting at the edge of the bed with bilateral grab bars on the bed. RN 1 stated the resident did not have an indication for the grab bars and did not need assistance with mobility or repositioning. The resident’s bed rail assessment dated 12/18/2025 indicated side rails were not indicated, the active orders did not include grab bars, and the eHR did not show informed consent from the responsible party. RN 1 stated the resident may have inherited the bed from a previous resident and that the grab bars were not removed. Resident 62 was admitted with dementia, hemiplegia and hemiparesis following cerebral infarction, and major depressive disorder. The MDS showed severely impaired cognition and maximal assistance needs for several activities of daily living, and the H&P noted fluctuating capacity to understand and make decisions. An order summary report from 12/3/2021 indicated bilateral side rails as an enabler, and the resident was observed lying in bed with bilateral side rails. RN 1 stated the side rails were used to aid bed mobility and repositioning and that the family requested them. However, the bed rail assessment dated 1/13/2026 indicated side rails were not indicated or requested, and RN 1 stated the assessment was incorrect and should have reflected the family request and current use.
Medication Administration Errors and Failure to Inform Residents
Penalty
Summary
Medications were not administered in accordance with professional standards of practice for two residents during a medication pass observed by surveyors. One LVN was observed at the medication cart with two medication cups already filled with medications. The LVN placed one cup in the top drawer of the cart and locked it, then entered one resident’s room and gave the medications from the second cup. The resident swallowed the medications with water, and the LVN did not identify the medications or explain their purpose before administration. During the same observation, the LVN was later seen returning to the medication cart after administering medications to another resident and unlocking the top drawer of Medication Cart 3 to remove a medication cup containing loose pills. The cup was labeled with another resident’s room number. The pre-prepared medications had been stored in the locked drawer of the medication cart before administration and were left unattended until the LVN retrieved them to give to that resident. During interview, the LVN stated she had forgotten to inform the first resident of the medications and their purpose, acknowledged the resident had a right to know what medications he was taking, and stated it was not the facility’s policy to hold opened medications in the cart or prepare more than one resident’s medications at a time because it could cause confusion. Resident 72 had diagnoses including DM, schizophrenia, major depressive disorder with severe psychotic symptoms, dysphagia, and hypertensive chronic kidney disease. His H&P stated he had the capacity to understand and make decisions, while the MDS indicated severely impaired cognition and need for assistance with several activities of daily living. Resident 82 had diagnoses including DM, schizophrenia, depression, hypertensive heart disease, and bipolar disorder. His H&P indicated fluctuating capacity to understand and make decisions, and his MDS indicated severely impaired cognition. The facility’s policy required medications to be administered at the time they were prepared, not pre-poured, and by the person who prepared them, and its resident rights policy stated residents have the right to be informed of their medical condition and participate in their care planning and treatment.
Failure to Monitor Side Effects of Divalproex Sodium
Penalty
Summary
The facility failed to monitor one resident for side effects related to divalproex sodium, which was ordered at 250 mg by mouth twice daily for bipolar disorder manifested by erratic mood swings. The resident’s record showed diagnoses of dementia and bipolar disorder, severe cognitive impairment on the MDS, moderate assistance needed with toileting, bathing, and footwear, and an H&P stating the resident did not have the capacity to consent. The resident’s care plan for behavioral patterns directed staff to administer divalproex sodium and to monitor for side effects every shift, with physician notification if any were present. During record review and interview, the resident’s active orders did not indicate monitoring for side effects related to divalproex sodium. The RN stated the medication should have been monitored for side effects, including hepatotoxicity, and the DON stated licensed nurses were responsible for monitoring for side effects of medications used to treat behavioral symptoms.
Medication Pass Errors and Pre-Prepared Medications
Penalty
Summary
The facility failed to ensure it was free of a medication error rate of five percent or greater after surveyors identified 2 medication errors out of 35 opportunities, resulting in a 5.71 percent error rate for 2 of 24 sampled residents. During a medication pass observation, an LVN administered medications to Resident 72 without first identifying the medications or explaining their purpose. The LVN was observed with two medication cups at the medication cart, placing one cup in the top drawer of the cart and locking it before entering the resident’s room with the second cup. Resident 72’s record showed diagnoses including DM, schizophrenia, major depressive disorder with severe psychotic symptoms, dysphagia, and hypertensive chronic kidney disease. The resident’s H&P indicated capacity to understand and make decisions, while the MDS indicated cognition was severely impaired and that the resident required maximal assistance with toileting, bathing, dressing, and personal hygiene, with set-up or clean-up assistance for eating. The resident’s order summary listed multiple scheduled medications, including amlodipine, aspirin, B-complex with C and folic acid, citalopram, lisinopril, metoprolol tartrate, quetiapine fumarate, and levetiracetam. During the same medication pass, the LVN was observed returning to the medication cart after administering medications to another resident and removing a medication cup containing loose pills from the locked top drawer. The cup was labeled with Resident 82’s room number, and the medications had been pre-prepared and stored in the cart before administration. Resident 82’s record showed diagnoses including DM, schizophrenia, depression, hypertensive heart disease, and bipolar disorder; the H&P indicated fluctuating capacity to understand and make decisions, and the MDS indicated severely impaired cognition. The resident’s order summary listed scheduled medications including metformin, aspirin, fenofibrate, folic acid, losartan potassium, multiple vitamin, and risperidone. The facility policy stated medications shall be administered at the time they are prepared, shall not be pre-poured, and the person who prepares the dose shall be the person who administers it; the resident rights policy stated residents have the right to be informed of their medical condition and to participate in their care and treatment.
Fortified Diet Orders Not Communicated During Meal Service
Penalty
Summary
The facility failed to ensure dietary staff followed fortified diet guidelines during lunch service for nine residents who were ordered fortified diets. During tray line observation on 2/4/2026 at 12:00 p.m., [NAME] 1 did not communicate the fortified diet orders written on the meal tickets, even though the tray and meal tickets on the cart indicated fortified diets. [NAME] 2, who was serving the food, did not add any additional food items per the fortified menu. During interviews later that day, [NAME] 2 stated butter was added to vegetables during meal service for fortified diets and that he relied on [NAME] 1 to communicate which trays were fortified diets. [NAME] 1 stated he was responsible for reviewing the meal tickets and communicating the diet orders, including fortified diets, and that fortified diets should be communicated and implemented during tray preparation. The Dietary Supervisor stated the facility did not ensure residents on fortified diets received the ordered fortified modifications to meet their nutritional needs, and the policy required extra margarine or butter to be added to food items at breakfast, lunch, and dinner for residents on fortified diets.
Arbitration Agreement Signed by Resident Without Decision-Making Capacity
Penalty
Summary
The facility failed to ensure the Arbitration Agreement was provided to and signed by an individual with decision-making capacity for one resident. Resident 10 was admitted with diagnoses including dementia and bipolar disorder, and the admission record identified RP 2 as the resident’s responsible party. The resident’s MDS dated 1/6/2026 indicated severely impaired cognitive skills for daily decision making, and the hospital psychosocial assessment noted RP 2 as the primary surrogate decision maker. The hospital H&P dated 12/24/2025 stated the resident did not have the capacity to consent. Despite this information, the Arbitration Agreement dated 12/17/2025 showed Resident 10 signed the agreement herself. The agreement stated that by signing, the resident agreed to have medical malpractice issues decided by neutral arbitration and gave up the right to a jury or court trial. Receptionist 1 stated she reviewed arbitration agreements with residents and/or their RP, but acknowledged the agreement should not have been reviewed with Resident 10 because she lacked decision-making capacity and had designated RP 2 as her surrogate decision maker. The Administrator also stated the agreement had to be reviewed with an individual with decision-making capabilities and that Resident 10 should not have signed it.
Improper Storage of Outside Food at Bedside
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility did not follow its policy titled, Food for Residents from Outside Sources, for one sampled resident. Resident 53 was admitted with diagnoses including DM, left BKA, CKD, and dementia. The resident's H&P indicated he could make needs known but could not make medical decisions, and the MDS showed severely impaired cognition, independence with eating, moderate assistance needed for toileting, bathing, dressing, and personal hygiene, and a therapeutic diet. The order summary indicated a consistent carbohydrate, no added salt diet with regular/thin consistency. During a concurrent observation and interview, Resident 53 was found awake and alert in bed with a clear plastic container of yellow food substance and two individual cardboard pizza boxes on the bedside table. The food was room temperature and unrefrigerated, and the resident stated a family member had brought the food the day before. Staff interviews indicated outside food should be labeled and refrigerated within one hour if the resident wanted to keep it, and that food left out overnight could make a resident ill. The facility policy stated prepared food brought in for a resident must be consumed within one hour or stored in the facility kitchen, nursing station refrigerator, or resident's personal refrigerator, and opened food must be sealed, dated, and disposed of within two days after opening.
Non-Operational Resident Call Light
Penalty
Summary
The facility failed to ensure a working call system was available in a resident’s bathroom and bathing area, and the call light for one sampled resident was found to be non-operational. The resident had diagnoses including epilepsy, cognitive communication deficit, traumatic brain injury, anxiety, acute embolism and thrombosis of the right popliteal vein, presence of a cardiac pacemaker, MI, acute and chronic kidney disease, anemia, and a history of falling. The resident’s H&P noted fluctuating capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills for daily decision making, with set-up or clean-up assistance needed for eating and dressing and moderate assistance needed for toileting and bathing. During observation, the resident was seen lying in bed with the call light attached to the sheet on the right side of the bed, but it had no push button and was not working. The resident stated the call light did not work. A CNA later confirmed the call light was non-operational and missing the button, and stated nursing staff would not know if the resident needed anything or had an emergency because the call light was not working. The CNA also stated staff were required to ensure call lights were in working order, but she had placed the call light near the resident without checking it. The MSA stated he was responsible for replacing and repairing broken call lights, that nursing staff were to notify him immediately when call lights were not working, and that he had not been informed about this resident’s call light. He also stated he was supposed to make morning rounds to check call lights but was too busy to complete the checks that morning, and the resident’s call light was not documented in the maintenance log.
Failure to Monitor a Resident and Maintain Ordered Fall Mats
Penalty
Summary
The facility failed to provide visual monitoring every two hours and failed to ensure floor mats were in place for two residents. One resident had diagnoses including atrial fibrillation, schizophrenia, hypertensive heart disease, heart failure, COPD, suicidal ideations, and difficulty walking, and his MDS indicated moderately impaired cognitive skills and a need for supervision or touching assistance with ADLs. The record showed he was not documented as being monitored between 9:50 a.m. on 2/1/2026 and 10:00 p.m. on 2/2/2026, and there was no documentation that exit door alarms were armed or actively engaged during the 3 p.m. to 11 p.m. shift on 2/2/2026. At 10:00 p.m., staff found the resident was not in bed during room rounds and conducted a facility-wide search. At 11:00 p.m., local authorities were notified. At 11:50 a.m., an LVN received a call from a general acute care hospital located approximately 9.5 miles from the facility that the resident had been located and arrangements would be made to return him. During interview, the resident stated he wheeled himself from his room through the hallways and exited through the back door without staff awareness, did not recall hearing an alarm, and was able to open the back gate and wheel himself to the street. Staff interviews indicated expectations for two-hour rounding and securing or arming exits, but the assigned LVN and CNA did not effectively monitor the resident's whereabouts. A second resident had diagnoses including paraplegia, dysphagia, dementia, and a history of falls, and her MDS indicated moderately impaired cognition and maximum assistance with ADLs. Her physician order and care plan directed bilateral floor mats to decrease the risk of injury related to falls. However, observations on three occasions showed only one floor mat on the right side of the bed and no floor mat on the left side. An LVN confirmed the resident was supposed to have bilateral floor mats on both sides of the bed and stated the missing mat left the resident at risk of injury if she fell from bed.
Insufficient Room Space in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet of room space per resident in 22 of 39 rooms. A review of the facility's Room Waiver Request Letter dated 2/9/2026 identified Rooms 11, 12, 14, 15, 17, 18, 21 through 36 as not meeting the 80 square foot per resident requirement. The letter stated that the lack of space on the new building code had no adverse effect on the health, safety, or well-being of the residents. During an interview on 2/9/2026 at 10:23 a.m., the Administrator stated she had not received any complaints about the room sizes and said the impact on resident care was minimal. She stated that all 22 rooms had sufficient space for Hoyer lifts, wheelchairs, and gurneys to enter and operate inside the rooms. Observations made throughout the survey from 2/2/2026 through 2/9/2026 found no adverse effects related to resident care, privacy, health, or safety from the living space being less than 80 square feet per resident. A review of the facility's Policy and Procedure titled Quality of Life- Homelike Environment, revised 4/2014, stated the facility was to ensure residents were provided with a safe, clean, comfortable, and homelike environment.
Failure to Follow Readmission Process and Improper Denial of Return from Hospital
Penalty
Summary
The deficiency involves the facility’s failure to follow its established readmission process for a hospitalized resident who had been medically cleared to return from a general acute care hospital (GACH). The resident had diagnoses including peripheral vascular disease, PTSD, and major depressive disorder, and had been initially admitted and later readmitted to the facility prior to the hospitalization. An MDS dated 1/5/2026 documented modified independence in cognitive skills for daily decision making, no physical or verbal behavioral symptoms directed toward others, and a need for moderate assistance with toileting, dressing, and personal hygiene. The resident was discharged to the GACH with return anticipated, and a prior H&P indicated the resident had capacity to understand and make decisions. When the GACH determined the resident was medically cleared for discharge back to the facility, the GACH case manager reported that the facility refused readmission before receiving any clinical documents. The case manager stated that clinical documents were not sent because the facility declined the readmission and that the facility cited aggressive behaviors as the reason, despite the resident being calm and exhibiting appropriate behavior at that time. Facility staff, including RN 1 and the Marketing Director (MD), described the usual readmission process as beginning with a phone call from the GACH followed by transmission of clinical documents for review by the DON or designee to determine whether the resident’s needs could be met, including any special treatments or isolation requirements. RN 1 stated there were few valid reasons to decline readmission, such as lack of available beds or required services not provided by the facility, and that aggressive behavior was never an acceptable reason. In this case, the receptionist reported receiving a call from the GACH about the resident’s potential readmission and transferring it to the MD, who was temporarily handling admissions. The MD acknowledged informing the GACH case manager that the facility would not accept the resident back due to behavior, referencing prior screaming at staff and a possible incident of hitting a staff member, and stated that the DON made the decision to deny readmission based on this past behavior. RN 1 confirmed that the facility had no clinical documents to review for this readmission and that the denial was made without such review. A census review for the date of the attempted return showed 11 empty beds, including six available for a male resident, indicating the facility could have accommodated the resident. Facility policies on bed-holds and admission criteria required that residents be permitted to return to an available bed and that appropriate medical records be received prior to or upon admission, which were not followed, resulting in the resident’s denial of return and an unnecessary nine-day stay at the GACH.
Failure to Revise Care Plan and Orders to Monitor Aggressive Behavior
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to include monitoring of aggressive behavior as recommended by the Interdisciplinary Team (IDT). The resident had diagnoses including peripheral vascular disease, PTSD, and major depressive disorder, and was assessed as having modified independence in cognitive skills for daily decision making, with moderate assistance needed for several ADLs. The resident’s history and physical indicated capacity to understand and make decisions. An SBAR dated 11/27/2025 documented that the resident exhibited behavioral symptoms such as agitation when frustrated and when he believed he was being targeted by staff. On 11/28/2025, the IDT met with the resident to address issues related to his verbal aggression toward staff. The IDT Conference Record documented that the team discussed his behavior of verbal aggression and recommended interventions for the plan of care that included continuing to monitor his behavior. However, the resident’s care plan for behavioral symptoms, dated the same day, listed manifestations such as aggressive behavior, verbal abuse, and sudden angry outbursts, but did not include any intervention to monitor these behaviors. LVN 1 confirmed during interview and concurrent record review that the care plan should have been revised to reflect the IDT’s recommendation to monitor the resident’s behavior. Further review of the resident’s active orders on 2/3/2026 showed no orders to monitor for aggressive behavior, verbal abuse, or sudden angry outbursts. LVN 1 stated that a behavior monitoring order would have prompted licensed nurses to document the frequency of behaviors every shift to gather information and determine changes in frequency for physician notification. RN 1 stated that the resident was known to have aggressive behavior and had a 1:1 sitter for safety, and that the IDT’s recommendation to monitor behavior should have been communicated to the physician to obtain an order for every-shift monitoring. RN 1 also stated that the IDT was responsible for updating the care plan so licensed nurses would be aware of the need to monitor and document the frequency of the resident’s aggressive behavior. Facility policies on comprehensive care plans and behavioral assessment indicated that care plans are to be revised as resident information and condition change, and that the IDT evaluates behavioral symptoms and develops a plan of care accordingly.
Failure to Implement and Document Fall Precautions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and document fall risk interventions, including visual checks and monitoring, for a resident identified as a fall risk, which resulted in an unwitnessed fall. The resident had diagnoses including age-related osteoporosis with pathological fracture, history of falling, dementia, and osteoarthritis of both hips. An H&P noted the resident had capacity to understand and make decisions, while an MDS assessment documented severely impaired cognitive skills for daily decision-making, bilateral lower extremity impairment, and the need for assistance with transfers and ambulation, with wheelchair use for mobility. Multiple care plans identified the resident as at risk for falls due to history of falls, hypoxia, impaired balance, and brain injury, with goals for the resident to remain free of falls and interventions including placement on the Falling Star (Yellow Star) Program and initiation of fall risk precautions. Care plans and the facility’s fall prevention program required monitoring and documentation of fall risk interventions, including closer monitoring, frequent rounds, and visual checks for residents on fall precautions. The Falling Star Program used a yellow star outside the resident’s room to identify fall risk and called for the bed to be in the lowest position and floor mats on both sides of the bed. The Quality Assurance Nurse stated that residents on fall precautions were to be monitored closely by CNAs, with documentation of monitoring on ADL task flowsheets, and that visual checks required hourly documentation on a Visual Observation Log posted in the resident’s room. However, review of nursing progress notes from 1/20/2026 through 1/23/2026 and the ADL documentation for January 2026 showed no documented monitoring or visual checks for the resident prior to the fall, with the last CNA entry recorded the night before the fall. The QAN acknowledged that in the absence of documentation, there was no way to determine whether fall risk monitoring or interventions were implemented. On the date of the incident, a Change in Condition evaluation documented that the resident was found on her right side on the floor, with a skin tear to the right upper extremity, and the resident stated, "I rolled out of bed." A Post Fall Evaluation recorded that the unwitnessed fall occurred in the resident’s room when the resident rolled out of bed, and that no floor mat was present at the time of the fall. Subsequent nursing documentation noted an acute right pelvic fracture and transfer to a general acute care hospital for further evaluation and treatment. Staff interviews revealed inconsistent awareness and implementation of fall precautions: one CNA reported making 20–30 minute rounds and visual checks on fall-risk residents but not documenting this, another CNA described the resident’s repeated attempts to get out of bed and into a wheelchair, and a nurse stated she did not know the resident was a fall risk and therefore did not implement increased visual checks. Observations after the fall showed the resident attempting to get out of bed, with low bed and floor mats in place, but without a Falling Star symbol posted outside the room, despite the resident being on the Falling Star Program. Facility policies on charting, falls and fall risk management, and assessing falls required staff to monitor, evaluate, and document interventions and resident responses, which were not carried out or documented as required for this resident.
Failure to Arrange Psychology Consult After Onset of Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to arrange a psychology consult for a resident after the onset of aggressive behavioral symptoms, despite multiple assessments and care plans indicating the need for such an evaluation. The resident had diagnoses including peripheral vascular disease, PTSD, and major depressive disorder, and was documented as having the capacity to understand and make decisions. An MDS assessment showed modified independence in cognitive skills for daily decision-making and a need for moderate assistance with toileting, dressing, and personal hygiene. On 11/27/2025, an SBAR documented that the resident exhibited behavioral symptoms, including agitation when frustrated and a belief that he was being targeted by staff. Following this change in condition, the resident’s care plans titled “Aggressive Outbursts” and “Behavioral Symptoms,” dated 11/27/2025 and 11/28/2025 respectively, identified aggressive behavior, verbal abuse, and sudden angry outbursts, and specifically included interventions for a psychological evaluation. An IDT conference record dated 11/28/2025 showed that the team met with the resident to discuss verbal aggression toward staff and recommended a referral to psychology for a consultation. Despite these documented recommendations and care plan interventions, interviews and record review revealed that no psychology evaluation was completed and no psychology note was found in the resident’s medical record after the behavioral change on 11/27/2025. The SSD stated that when the IDT recommended a psychology referral, the referral should be made so the psychologist could evaluate the resident as soon as possible after behavioral symptoms. The psychologist reported he did not recall being informed of the resident’s behavioral change and stated he had not been made aware of the need for an evaluation. Facility staff, including the SSD and RN 1, stated that psychological evaluations were important for residents to express feelings, identify root causes of behavior, and develop coping skills, and that without the recommended evaluation the resident was at risk for psychological distress, poor coping skills, and continuation of aggressive behavior. The facility’s behavioral health policy and the Social Services Designee job description indicated that the facility was responsible for providing behavioral health services as needed and coordinating with outside psychology professionals, which did not occur in this case.
Psychotropic Medications Administered Without Prior Informed Consent
Penalty
Summary
Licensed nursing staff failed to obtain informed consent prior to administering psychotropic medications to a resident diagnosed with paranoid schizophrenia and bipolar disorder. The resident, who had fluctuating capacity to understand and make decisions and was assessed as moderately impaired in cognitive skills, was admitted with orders for multiple psychotropic medications, including quetiapine fumarate, valproic acid, and olanzapine. According to the Medication Administration Report, these medications were administered starting on 7/17/2025. However, the Verification of Informed Consent form for these medications was not completed until 7/22/2025, indicating that the resident received psychotropic medications for several days before consent was obtained. Interviews with a registered nurse confirmed that the medications were given prior to obtaining the required informed consent, which was contrary to the facility's policy and procedure mandating written informed consent before initiating psychoactive medication use.
Failure to Revise Fall Care Plan After Multiple Resident Falls
Penalty
Summary
Licensed nursing staff failed to revise the fall care plan for a resident after multiple falls, as evidenced by record reviews and staff interviews. The resident, who was admitted with diagnoses including paranoid schizophrenia and bipolar disorder, had fluctuating capacity to understand and make decisions, and required supervision for activities of daily living due to moderately impaired cognitive skills. Despite documented falls on several occasions, the care plan interventions were not updated after each incident, and no new interventions were developed to address the recurring falls. Interviews with nursing staff confirmed that care plans should be revised after every fall, and that the lack of updated interventions meant there were no additional measures in place to minimize future falls. The facility's policy required staff to implement additional or different interventions if falls reoccurred, or to justify the continuation of current interventions, but this was not followed. As a result, the resident did not have effective interventions in place to minimize future falls and injuries.
Failure to Communicate and Document Change in Condition After Resident Fall
Penalty
Summary
The facility failed to identify, document, and communicate changes in condition for a resident following an unwitnessed fall. Certified Nursing Assistants (CNAs) observed new onset of shoulder pain and limited range of motion in the resident while assisting with dressing on two separate occasions, but did not effectively communicate these changes to the Licensed Vocational Nurse (LVN) and did not complete the required Stop and Watch form, which is the facility's designated CNA-to-LVN communication tool. Additionally, one CNA stated she verbally notified the LVN but did not document the change, while another CNA admitted to forgetting to complete the form. The LVNs involved reported not being made aware of the resident's pain or range of motion limitations, and as a result, did not perform further assessments or notify the physician for further evaluation. On a separate occasion, an LVN noted new skin redness to the resident's right shoulder three days after the fall but failed to document the finding, assess for range of motion changes, or notify the physician or RN Supervisor. The LVN stated that the omission was due to being busy with medication administration. The lack of documentation and communication meant that other licensed nurses and the physician were not made aware of the resident's new symptoms, and no change of condition note was initiated. Interviews with other staff confirmed that the facility's policy required such findings to be documented and communicated promptly, especially following a fall. The resident involved had a history of falling, hemiplegia, hemiparesis, aphasia, dementia, and mild intellectual disabilities, and required moderate assistance with activities of daily living. The resident's care plan specified that nurses were to call the physician for any significant change of condition and assess for nonverbal signs and symptoms of pain. Despite these requirements, the new onset of pain and functional decline was not effectively communicated or documented, resulting in a delay in physician notification and the discovery of a clavicle fracture and significant bruising several days after the initial fall.
Failure of RN Supervisor to Complete Post-Fall Assessment and Incident Report
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) supervisor completed the post-fall incident report and assessment as required by facility policy for a resident who experienced an unwitnessed fall. The resident, who had a history of falls, hemiplegia, hemiparesis, aphasia, dementia, and mild intellectual disabilities, was found lying in the hallway and reported a fall. An initial assessment by an LVN documented a hematoma on the back of the resident's head, and the physician was notified, resulting in an order for a skull x-ray. Despite facility policy stating that the RN supervisor on duty must complete the Fall Incident Report within 24 hours and conduct a thorough post-fall assessment, the report was completed by the LVN instead. The RN supervisor, who was on lunch break at the time of the fall, did not conduct the required assessment or complete the incident report, stating he was unaware of the policy. The Director of Nursing confirmed that the RN supervisor was responsible for conducting a comprehensive assessment, even if an LVN had already performed an initial evaluation. Seven days after the fall, the resident complained of right shoulder pain and discoloration, leading to an x-ray that revealed a displaced, acute comminuted fracture of the right clavicle. The facility's Quality Assurance Nurse acknowledged that adherence to policy would have prompted an RN-level assessment, which could have identified injuries not detected during the LVN's assessment.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Behavioral Management
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident physically attacked another. A resident with diagnoses including schizophrenia, mood disorder, and other medical conditions exhibited erratic mood swings, auditory hallucinations, and aggressive behaviors over several days. Despite these behaviors being documented in the Medication Administration Record (MAR), there was no detailed description of the behaviors or documentation of staff interventions. The facility did not implement its own Abuse Prevention/Prohibition policy, which required understanding and monitoring behavioral symptoms that could increase the risk of abuse, such as aggression and outbursts. There was no individualized care plan addressing the resident's schizophrenia, nor were interventions developed to monitor and re-evaluate the effectiveness of behavioral management strategies. The existing care plans for psychosocial well-being and mood patterns were not followed, as there was no documentation that staff listened attentively or addressed the resident's concerns during periods of erratic mood swings and hallucinations. Staff interviews revealed that aggressive and disruptive behaviors were observed but not consistently reported or documented, and there was a lack of communication among staff regarding these behaviors. As a result of these failures, the resident with schizophrenia physically assaulted another resident, causing visible injury, pain, and emotional distress. The assaulted resident expressed feeling unsafe and fearful of being alone, and required pain medication for the injuries sustained. The incident was witnessed by staff, and subsequent interviews confirmed that the aggressive behaviors had been ongoing and inadequately managed, with insufficient documentation and monitoring to prevent harm.
Failure to Provide Adequate Supervision for High-Risk Elopement Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a resident identified as high risk for elopement. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and anxiety disorder, was assessed as having moderate cognitive impairment and required partial to moderate assistance with activities of daily living. The resident had a documented history of elopement attempts and had verbally expressed a desire to leave the facility. Despite these risk factors, the resident was able to remove her wander guard bracelet, which she found uncomfortable, and refused to have it reapplied. The care plan was updated to indicate frequent visual checks, but did not specify the frequency or documentation requirements for these checks. On the day of the incident, the resident was able to leave the facility without staff knowledge by using a chair to exit through a window. She spent the day shopping and returned to the facility without injury, only informing her sister of her whereabouts. Interviews with staff revealed that the care plan's instructions for frequent visual checks were unclear, lacking specific intervals and documentation protocols. Both the LVN and DON acknowledged that the care plan should have been more precise to ensure the resident's safety and adequate supervision. A review of facility policies indicated that individualized care plans should include measurable objectives and timetables, and that resident safety and supervision are facility-wide priorities. However, the lack of specificity in the resident's care plan and the absence of clear monitoring procedures contributed to the failure to prevent the resident's elopement.
Failure to Assess and Document Vital Signs Prior to Antihypertensive Medication Administration
Penalty
Summary
The facility failed to ensure that a resident's blood pressure and pulse were assessed and documented prior to the administration of hydralazine and lisinopril, as required by physician orders and the resident's care plan. The resident, who had diagnoses including hypertensive heart disease, chronic pulmonary edema, and schizophrenia, was admitted with specific medication orders that required holding the blood pressure medications if the systolic blood pressure was less than 110 mm Hg or the pulse was less than 60 beats per minute. Despite these clear parameters, the electronic medication administration record (eMAR) and vital signs summary showed no documentation of blood pressure or pulse measurements prior to medication administration on multiple occasions. Interviews with the DON and an LVN revealed that the lack of documentation was due to the LVN's failure to input the necessary supplemental documentation fields in the eMAR, which prevented nurses from recording the required vital signs before administering the medications. As a result, there was no evidence that the resident's vital signs were checked as ordered, and the medications were administered without the necessary assessments. Facility policies and job descriptions reviewed indicated that comprehensive care planning and proper medication administration and documentation were required, but these were not followed in this instance.
Staff Unfamiliarity with Food Storage Policy Poses Risk
Penalty
Summary
The facility failed to ensure that staff were knowledgeable about the policy regarding the use and storage of food brought to residents by family and other visitors. This deficiency was identified through observations, interviews, and record reviews, revealing that two staff members were unable to verbalize the policy. The policy, titled 'Food for Residents from Outside Sources,' outlines procedures for monitoring and storing non-perishable and perishable foods to ensure safe and sanitary conditions. However, staff interviews indicated a lack of familiarity with these procedures, which could potentially lead to harmful bacterial growth and cross-contamination, posing a risk of foodborne illness to the 88 medically compromised residents who store food in the facility's refrigerators. Interviews with various staff members, including the Dietary Supervisor, Licensed Vocational Nurses, and the Quality Assurance Nurse, highlighted inconsistencies in understanding and implementing the policy. The Dietary Supervisor mentioned that the facility did not have a designated refrigerator for residents' food in the kitchen, and the responsibility for maintaining the resident's refrigerator was unclear. Licensed Vocational Nurses expressed limited knowledge of the policy, with one nurse incorrectly stating that food could not be stored in the kitchen. The Quality Assurance Nurse, responsible for monitoring food safety, emphasized the importance of staff awareness of the policy to prevent food spoilage and bacterial growth. These findings indicate a gap in staff training and communication regarding the facility's food storage policy.
Infection Control Deficiencies in Housekeeping and Nursing Practices
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by housekeeping and nursing staff. During an observation, a housekeeper was seen collecting trash from a resident's room with gloved hands, removing the gloves, and then exiting the room without performing hand hygiene. The housekeeper then touched another trash can lid in the hallway without washing her hands. In an interview, the housekeeper acknowledged the importance of handwashing to prevent the spread of infection but admitted to forgetting on this occasion. Additionally, a nurse failed to sanitize a high-traffic surface area contaminated with body fluids. An observation noted a resident with mucus dripping from his nose, which landed on the nursing station counter. The nurse placed a paper towel over the mucus, handed it to the resident, and walked away without disinfecting the counter or washing her hands. The nurse later admitted that she should have disinfected the counter and washed her hands to prevent potential exposure to other residents and visitors. Furthermore, the facility did not ensure that a resident's nebulizer equipment was stored properly. The nebulizer machine, mask, and tubing were observed on the floor, with the tubing undated. The resident, who had chronic obstructive pulmonary disease, required the nebulizer for medication administration. The nurse confirmed that the equipment should have been placed on a table, dated, and stored in a plastic bag to prevent contamination and reduce the risk of respiratory infection.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during an inspection of the Station A Medication Room and Medication Carts. A bottle of Sriracha sauce was found stored alongside medications, posing a risk of cross-contamination. Additionally, expired niacin tablets were not removed from the medication stock, which could lead to ineffective or unsafe administration. An unapproved container was also used for measuring water for G-tube flushes, which was not in accordance with facility standards. Further deficiencies were noted in the storage and labeling of various medications, including vitamin B12, latanoprost ophthalmic solution, insulin glargine, metoclopramide oral solution, cranberry tablets, and vitamin D3 tablets. These medications were either expired, not stored according to manufacturer requirements, or lacked proper labeling, such as open dates. This affected several residents, including those with conditions requiring specific medication regimens, such as glaucoma and diabetes, potentially compromising their treatment. The facility also failed to manage controlled medications properly. Fifteen controlled medications for discharged residents or discontinued orders were not removed from the medication cart and were not documented daily in the controlled medication accountability record. This oversight involved medications such as clonazepam, lorazepam, temazepam, hydrocodone-acetaminophen, zolpidem, tramadol, and diphenoxylate-atropine, affecting multiple residents. The facility's Director of Nursing acknowledged the lapses in medication management and the potential risks associated with these deficiencies.
Inadequate Training and Competency in Kitchen Sanitation Procedures
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in handling food safety procedures, specifically regarding the operation of dishwashing equipment and the use of sanitizing solutions. During observations and interviews, it was found that Dietary Aides were unable to correctly verbalize the acceptable temperature for the low-temperature dishmachine and the correct chlorine concentration range. This lack of knowledge was evident when Dietary Aide 1 incorrectly stated the temperature range and was unsure of the chlorine concentration range, while Dietary Aide 2 initially provided incorrect information and later admitted to not knowing the acceptable chlorine concentration range. Further investigation revealed that the facility's policies and procedures were not being followed. The facility's policy indicated that the low-temperature dishmachine should operate at a range of 120 F to 140 F, with a chlorine concentration of 50-100 ppm. However, the Dietary Aides were not adhering to these guidelines, as evidenced by their inability to accurately determine the concentration of the sanitizing solution using test strips. Additionally, the facility's competency checklists for the Dietary Aides did not include verification for dishmachine temperatures or sanitizer concentration checks, indicating a gap in training and competency evaluation. The facility also failed to ensure proper use of quaternary ammonium compound (QUAT) sanitizer. Observations showed that staff were not following the manufacturer's guidelines for testing the QUAT sanitizer concentration, which should be between 150-400 ppm at a minimum temperature of 75 F. Instead, the facility's log indicated a testing temperature range of 69-71 F, which did not align with the manufacturer's instructions. This discrepancy in following proper procedures for sanitizing solutions posed a risk of unsanitized dishes, potentially leading to foodborne illnesses among the 87 medically compromised residents who received food and ice from the kitchen.
Incorrect Portion Sizes Served to Residents
Penalty
Summary
The facility failed to adhere to its menu guidelines, resulting in incorrect portion sizes being served to residents. Specifically, 75 out of 88 residents on a regular texture diet received only 1/3 cup of sweet corn salad instead of the prescribed 1/2 cup. This discrepancy was due to the use of an incorrect scoop size by a staff member, who misread the menu spreadsheet. The Dietary Supervisor confirmed the error and acknowledged that using a smaller scoop could lead to residents not receiving adequate nutrition, potentially resulting in unintended weight loss. The facility's recipe and policy documents also indicated the correct portion size should have been 1/2 cup. Additionally, four out of six residents on a renal diet were served less than the required portion of wheat pasta with margarine because a regular serving spoon was used instead of the specified spoodle. The Dietary Supervisor noted that the use of incorrect utensils could result in residents receiving fewer calories than needed, which could negatively impact their nutritional status. The Registered Dietitian emphasized the importance of using the correct scoops and utensils to ensure proper portion sizes are served, as outlined in the facility's policies and procedures.
Deficiencies in Food Quality and Temperature Control
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature. Observations revealed that the sweet corn salad was served at 62 degrees Fahrenheit, which is above the recommended temperature for cold foods, and the lettuce was wilted. Additionally, the broccoli was overcooked, mushy, and lacked seasoning, affecting its flavor and appearance. These deficiencies were observed during meal service on two consecutive days, impacting a significant number of residents, including those at risk of unplanned weight loss. Resident 34, who has a history of polyneuropathy, COPD, unspecified protein-calorie malnutrition, and chronic kidney disease, expressed dissatisfaction with the food, stating it did not taste or look good. Resident 70, with diagnoses including acute pyelonephritis, unspecified protein-calorie malnutrition, and COPD, also reported that the food was unappealing in taste and appearance. Both residents were on regular diets, with Resident 70 requiring a fortified diet. The facility's failure to maintain proper food quality and temperature potentially affected the nutritional intake of these residents. The facility's policies and procedures for meal service and food preparation were not adhered to, as evidenced by the improper handling and serving of cold and hot foods. The Dietary Supervisor and Registered Dietitian acknowledged the issues with food temperature and preparation, noting that the corn salad was improperly stored and served, and the broccoli was overcooked and unseasoned. These lapses in food service could lead to decreased meal intake and potential weight loss among residents, as the food did not meet the standards for flavor, appearance, and temperature as outlined in the facility's guidelines.
Failure to Prepare Pureed Foods to IDDSI Standards
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs for residents on a pureed diet, specifically those requiring IDDSI Level 4 consistency. During an observation, the pureed Cajun country rice was found to be sticky, did not pass the spoon tilt test, and failed to hold its shape on the plate. This inconsistency was noted during a trayline observation and confirmed by the Dietary Supervisor, who acknowledged that the pureed diet should have a pudding-like consistency, be smooth, and able to hold its shape. The facility's recipe for pureed starches indicated that the finished product should be smooth, free of lumps, and meet IDDSI Level 4 testing requirements, which the rice did not. The Registered Dietitian revealed that the IDDSI diets had not been implemented, and the Dietary Supervisor had not attended the necessary training. The facility's policies and procedures required the use of approved recipes and a diet manual, which were not adequately followed. The lack of training and adherence to IDDSI guidelines resulted in the potential for residents to experience difficulty swallowing, decreased food intake, and unintended weight loss. The deficiency affected 8 out of 88 residents on a pureed diet, posing a risk of choking and aspiration.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices, as evidenced by multiple observations of unclean kitchen equipment and areas. Dust buildup was noted on the vents of the reach-in freezer, kitchen vents, and kitchen hood, with the Dietary Supervisor (DS) acknowledging the potential for bacterial growth and cross-contamination. The ice machine also had a significant dirt buildup, which the DS attributed to corrosion and calcium deposits, posing a risk of contamination to the ice consumed by residents. Further deficiencies were observed in the handling and storage of kitchen equipment and utensils. Pans were stacked wet, which the DS admitted could lead to bacterial growth. Dented cans were found stored with non-dented cans, contrary to the facility's policy, raising concerns about potential contamination from metal particles. Additionally, staff failed to adhere to proper handwashing protocols, with instances of staff handling food and clean dishes after touching dirty surfaces without washing their hands, increasing the risk of cross-contamination. The facility also failed to ensure that equipment and utensils were smooth and easy to clean. The can opener blade was chipped, storage racks had peeling paint, and resident trays were cracked, all of which could harbor bacteria. The scoop storage was rusted, and the freezer lacked a thermometer for temperature monitoring, which is crucial for preventing food spoilage. The emergency water storage area was cluttered with trash, and storage racks were not elevated to the required height, hindering proper cleaning and increasing the risk of contamination.
Failure to Honor Resident Rights and Dignity
Penalty
Summary
The facility failed to honor the rights and dignity of two residents, leading to deficiencies in their care. For one resident, a Certified Nursing Assistant (CNA) was observed watching television on her personal cellular phone with earphones in both ears while feeding the resident. This action compromised the resident's safety and dignity, as the CNA admitted she would not have been able to respond if the resident choked. The CNA acknowledged that this was not an acceptable practice and did not honor the resident's dignity and well-being. Additionally, the facility did not ensure that a bioethics committee meeting was held for the same resident, who was deemed unable to make medical decisions. Despite the resident's cognitive skills being intact according to a previous assessment, a later History and Physical indicated the resident lacked decision-making capacity. The facility administered psychotropic medication without consulting a responsible party or representative, as the resident did not have a public guardian or responsible party to make medical decisions on their behalf. For another resident, the facility also failed to obtain a public guardian or hold a bioethics committee meeting before administering psychotropic medication. This resident was diagnosed with schizophrenia, anxiety disorder, and depression, and was deemed unable to make medical decisions. The Social Services Director admitted that an application for public guardianship should have been initiated earlier, and the resident's right to have sound medical decisions made on their behalf was not honored. The facility's policies required informed consent from a representative if a resident was not capable of giving consent, which was not followed in these cases.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent for the administration of psychotropic medications was properly obtained for two residents, Resident 3 and Resident 4. Resident 3, who was diagnosed with schizoaffective disorder and other conditions, was administered haloperidol without informed consent. Despite having intact cognitive skills for daily decision-making according to the Minimum Data Set, Resident 3's History and Physical indicated a lack of capacity to make medical decisions. The Social Services Director confirmed that Resident 3 did not have a responsible party or public guardian, and the bioethics committee should have been involved before any medical decisions were made. However, this process was not followed, and informed consent was not obtained for the administration of psychotropic medication. Resident 4, diagnosed with schizophrenia, anxiety disorder, and depression, also did not have informed consent properly documented for psychotropic medication administration. The Minimum Data Set indicated severe cognitive impairment, and the History and Physical confirmed the resident's incapacity to make medical decisions. Despite this, the informed consent form for Risperdal was incomplete, and consent for haloperidol was incorrectly obtained from the resident himself, who was not capable of providing it. The Social Services Director noted that Resident 4 lacked a responsible party or public guardian, and the bioethics committee should have been consulted, but this step was not taken. The facility's policies required informed consent to be obtained from a resident's representative if the resident was not capable of giving consent. In both cases, the facility did not adhere to its policies, as informed consent was not properly obtained or documented, and the necessary involvement of a bioethics committee or responsible party was overlooked. This led to the administration of psychotropic medications without proper consent, violating the residents' rights to be fully informed and involved in their care decisions.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, leading to a potential delay or inability for these residents to obtain necessary care and services. Resident 72, who has a history of type 2 diabetes mellitus, chronic kidney disease, muscle wasting, and difficulty walking, was observed on multiple occasions with the call light hanging from the bedside nightstand, out of reach. Despite care plans indicating the need for the call light to be within reach to prevent falls, observations and interviews with staff confirmed that the call light was not accessible to Resident 72. Similarly, Resident 86, who suffers from dementia, dysphagia, muscle wasting, and major depressive disorder, was observed with the call light on the floor behind the bed, making it inaccessible. The resident's care plan also emphasized the importance of having the call light within reach to anticipate and meet care needs. Observations and staff interviews confirmed that the call light was not within reach, which could prevent the resident from calling for help when needed. Interviews with CNAs and LVNs revealed that the staff acknowledged the importance of having the call light within reach for resident safety and communication. The facility's policy and procedures, as well as job duties for CNAs, require that the call light be kept within easy reach of residents. However, the observations indicated a failure to adhere to these guidelines, resulting in a deficiency in providing adequate care and safety for the residents involved.
Failure to Notify Physician of Subtherapeutic Phenobarbital Levels
Penalty
Summary
The facility failed to notify the physician of a resident's low blood level concentration of phenobarbital, a medication used to control seizures, for one of the sampled residents. This oversight was identified during a review of the resident's records, which showed that the resident had a history of epilepsy and other medical conditions. The resident's phenobarbital level was found to be subtherapeutic, with a reading of 8 ug/mL, significantly below the normal range of 14-40 ug/mL. Despite this, there was no documentation indicating that the physician was informed of the low levels, which could have allowed for an adjustment in the medication dosage. The deficiency was further highlighted when the resident experienced seizures, as documented in an SBAR note, which described the resident exhibiting stiff jerking movements and being difficult to arouse. The seizures necessitated emergency intervention, including the application of oxygen and calling 911. Interviews with the RN and the DON confirmed that the low phenobarbital levels were not communicated to the physician, which was against the facility's policy to notify the physician of any subtherapeutic laboratory results. This failure to communicate critical information potentially contributed to the resident's seizure episode.
Inaccurate MDS Coding for Resident's Dental Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for one resident was accurately coded to reflect the resident's oral and/or dental status. Specifically, the MDS for a resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, depression, and anxiety, was inaccurately coded as not having any oral and/or dental issues. However, during an observation and interview, it was noted that the resident did not have her upper and bottom teeth, and her dentures were placed on her bedside table. This discrepancy was confirmed by the Minimum Data Set Nurse (MDSN 1), who acknowledged that the MDS section L was incorrectly coded and should have reflected the resident's use of dentures. The inaccuracy in the MDS assessment resulted in incorrect data being transmitted to the Centers for Medicare and Medicaid Services (CMS), which had the potential to negatively affect the resident's care plan and delivery of necessary care and services. The facility's policy and procedure titled 'Certifying Accuracy of the Resident Assessment' requires qualified professionals to certify the accuracy of the MDS sections they complete. The failure to accurately code the resident's oral and/or dental status in the MDS highlights a deficiency in the facility's assessment process.
Inaccurate PASARR Screening for Resident
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASARR) Level I screening for a resident, omitting diagnoses of depression and anxiety. This oversight was identified during a review of the resident's Face Sheet and Minimum Data Set (MDS), which indicated active diagnoses of depression and anxiety. The PASARR Level I, dated several months prior, incorrectly stated that the resident did not have a serious mental illness. This discrepancy was confirmed during an interview with the Director of Nursing (DON), who acknowledged the error and its potential impact on the resident's care. The resident, who was admitted and later readmitted to the facility, had a medical history that included depression, anxiety, hypertension, dementia, and diabetes mellitus. The inaccurate PASARR Level I screening increased the risk that the resident would not receive the necessary specialized care and services for their mental health conditions, as the facility's policy required a Level II review for residents with serious mental disorders. The DON emphasized the importance of an accurate PASARR to ensure appropriate care and prevent a decline in the resident's health and well-being.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Compton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lighthouse Healthcare Center | 1.7 mi | ★★★★★ | 2 | 0 |
| California Post-acute Care | 2.6 mi | ★★★★★ | 65 | 0 |
| Lynwood Post Acute Care Center | 2.6 mi | ★★★★★ | 34 | 0 |
| Granada Post Acute | 2.6 mi | ★★★★★ | 2 | 0 |
| Meadow Creek Post-acute | 2.8 mi | ★★★★★ | 16 | 0 |
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