Sherman Oaks Hospital Snf Dp
Inspection history, citations, penalties and survey trends for this long-term care facility in Sherman Oaks, California.
- Location
- 4929 Van Nuys Blvd, Sherman Oaks, California 91403
- CMS Provider Number
- 555885
- Inspections on file
- 18
- Latest survey
- April 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sherman Oaks Hospital Snf Dp during CMS and state inspections, most recent first.
Nursing staff failed to follow physician orders and facility policy for flushing g-tubes with water before, after, and between medication administrations for three residents with severe cognitive impairment and feeding tubes. In each case, staff either did not flush with the required amount of water or omitted flushing between medications, as observed and confirmed by interviews and record reviews.
The facility failed to ensure its medication error rate remained below 5%, with four errors out of 26 observed opportunities. Two residents with g-tubes did not have their tubes flushed with water between medication administrations, as required by physician orders and facility policy. Nurses acknowledged missing the required flushes, and the Director of Subacute confirmed these were medication errors.
Surveyors found that kitchen staff failed to label opened boxes of bacon, sausage, and a tray of eggs with open or use by dates, as required by facility policy. This lapse in food storage practices had the potential to affect a medically compromised resident who received food from the kitchen.
Two residents who were dependent on staff for all activities of daily living and had significant medical conditions were found with their call lights out of reach, despite care plans and facility policy requiring call lights to be accessible at all times. Staff confirmed during observations and interviews that the call lights should have been placed within reach, but this was not done after providing care.
A resident with chronic respiratory failure, seizure disorder, and a tracheostomy experienced a significant change in condition, including fever and increased secretions. Nursing staff observed these symptoms late at night but did not notify the attending physician until approximately six hours later, resulting in a delay in obtaining new medical orders. Staff interviews and record review confirmed that this delay was not in accordance with facility policy for timely physician notification.
A resident with a history of deep tissue injury and significant cognitive and physical impairments was observed with heels resting on the mattress, despite physician orders and a care plan requiring heels to be floated on two pillows. A nurse confirmed the intervention was not followed, in violation of facility policy for pressure ulcer management.
A resident with chronic respiratory failure, encephalopathy, and dementia, who was fully dependent on staff, was observed lying in bed with the bed brakes unlocked and no staff present. A nurse confirmed this was unsafe, and the bed's manual requires brakes to be applied whenever a resident is in bed.
A resident with significant medical needs and an indwelling urinary catheter was observed with catheter tubing that was looped and not draining properly, despite care plan and facility policy requirements to keep tubing free of kinks and obstructions. A nurse confirmed the improper positioning, which could impede urine flow and increase infection risk.
A resident receiving TPN via a PICC line did not have the TPN bag and tubing labeled with the date and time they were started, as required by facility policy. This lapse was confirmed by an RN during observation, despite the resident's care plan specifying adherence to protocol for tubing changes. The resident had significant medical needs and was fully dependent on staff.
A resident who was ventilator-dependent and required frequent suctioning had a Yankauer suction catheter in use that was not labeled with the date it was to be changed next, as required by facility policy. Staff interviews confirmed that all respiratory equipment should be labeled after being changed, but the catheter in the resident's room lacked this information, making it unclear when it was last replaced and placing the resident at risk for infection.
Two residents experienced inaccurate medical record documentation: one received a different form of docusate sodium than what was ordered, and another was administered Eliquis despite documentation of bleeding. Staff failed to clarify orders and document care accurately, resulting in discrepancies between physician orders and actual care provided.
The facility did not follow its antibiotic stewardship policy for two residents by failing to monitor and document antibiotic use, side effects, and adverse reactions, and by not completing the infection control surveillance log for antibiotic therapy. Staff interviews confirmed that required monitoring and documentation were not performed, and key information was missing from surveillance records.
The facility failed to ensure its Infection Preventionist was qualified and competent in managing the infection control program, as evidenced by a lack of monitoring for antibiotic use and adverse reactions in a resident, and incomplete documentation in the Infection Control Surveillance Log for another resident receiving antibiotics. The IP had not established required surveillance processes and had not fulfilled job description requirements.
The facility failed to establish and implement a policy on enhanced barrier precautions (EBP) to reduce the transmission of multidrug-resistant organisms (MDROs) in four residents. Staff did not follow EBP protocols, such as wearing gowns during high-contact care activities, despite the residents' high risk of infection. The Nurse Manager, Infection Preventionist, and Chief Nursing Officer acknowledged the lack of EBP implementation and staff training.
The facility failed to rotate subcutaneous injection sites for three residents receiving heparin, enoxaparin sodium (Lovenox), and Lantus insulin, leading to potential risks of bruising and bleeding. This was confirmed by the MDSC-RN, PHARM 1, and the NM, and was against the facility's policy and prescribing information for these medications.
The facility failed to act on pharmacist recommendations for three residents, including not tapering methadone dosage, not documenting conditions for lorazepam administration, and not discontinuing Robitussin when not in use.
The facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous injection sites for three residents receiving heparin, enoxaparin sodium (Lovenox), and Lantus insulin. This failure was confirmed by the MDSC-RN, pharmacist, and NM, and was identified as a significant medication error by the surveyors.
The facility failed to adhere to food safety standards by not storing the ice scooper in a covered container, not ensuring a food service worker wore a hairnet, and not labeling an opened container of canola/extra virgin olive oil with an open date. These practices could lead to foodborne illnesses among residents.
The facility failed to maintain an infection prevention and control program, including not sanitizing a barcode scanner between uses, not implementing Enhanced Barrier Precautions during medication administration for residents with indwelling devices, and not discarding single-use normal saline vials after use.
The facility failed to develop and implement comprehensive care plans on enhanced barrier precaution isolation for two residents, leading to potential infection control issues. Both residents lacked appropriate signage and isolation carts, and the LVN did not wear a gown during medication administration. The facility did not adhere to its care planning policies, risking the spread of infection.
The facility failed to ensure adequate supervision by leaving a medication cup with ointments unattended in a shared room, involving two residents who were totally dependent on staff. This breach of policy posed a risk of accidental ingestion.
The facility failed to properly administer and document IV fluids for two residents. One resident's midline catheter dressing was not labeled with the date of the last change, and another resident's midline catheter care and dressing changes were not documented as required. These deficiencies were against the facility's policies and placed the residents at risk for complications.
The facility failed to ensure proper medication storage and labeling when an opened and unlabeled single-use vitamin A&D ointment packet was found in Medication Cart 2. The LVN and Nurse Manager confirmed that the ointment should have been discarded or labeled, indicating a lapse in following the facility's policies.
A facility failed to inspect a handheld nebulizer compressor by its due date, compromising a resident's respiratory care. The resident, in a persistent vegetative state, required routine and as-needed nebulizer treatments. Staff interviews revealed confusion over inspection responsibilities, and the Biomed Engineering Site Lead confirmed the nebulizer was out of service due to missed inspections.
Failure to Adhere to G-Tube Medication Flushing Protocols
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and facility policy for three residents who required medication administration via gastrostomy tube (g-tube). For one resident with chronic respiratory failure, ventilator dependence, and dysphagia, the physician's order and care plan required flushing the g-tube with 20-50 ml of water before and after medication administration. However, a registered nurse administered only 10 ml of water after the last medication, contrary to the order. The nurse acknowledged that this amount might not be sufficient and could result in clogging the g-tube. The Director of Subacute confirmed that the facility's policy was to flush with 30-50 ml of water after medication administration to ensure hydration and complete delivery of medication. Another resident with chronic hypoxemic respiratory failure, tracheostomy, and pneumonia also had orders to flush the g-tube with 20-50 ml of water before and after medication administration. During observation, a licensed vocational nurse administered two medications sequentially without flushing the tube in between, as required by facility policy. The pharmacist noted that the medications given had a moderate risk of interaction, and the lack of flushing could contribute to this risk, although no immediate action was required for most residents. A third resident with chronic respiratory failure, ventilator dependence, and dysphagia was also observed to have medications administered via g-tube without flushing with water between medications. The nurse involved admitted to missing the flush, and the Director of Subacute reiterated that the facility's policy is to flush with water between medications to prevent drug interactions. Review of the facility's medication administration policy confirmed the requirement to flush the tube with a minimum of 50 ml of water and to rinse the medication cup to ensure complete dosing.
Failure to Flush G-Tubes Between Medications Results in High Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a calculated error rate of 15.38% based on four medication errors out of 26 observed opportunities. The errors involved two residents who were dependent on staff for activities of daily living and had gastrostomy tubes (g-tubes) for medication and nutrition administration. Both residents had physician orders and care plans specifying that their g-tubes should be flushed with water before and after medication administration, as well as between medications, to maintain tube patency and ensure proper medication delivery. In the case of one resident, a nurse administered crushed Keppra mixed with water via the g-tube, followed by additional water to flush the remaining medication, and then administered crushed fluconazole. The nurse did not flush the g-tube with water between the two medications, contrary to facility policy and the resident's care plan. A pharmacist interview confirmed that administering Keppra and fluconazole in this manner could have moderate drug interactions, and the facility's policy required flushing between medications to prevent such issues. For another resident, a nurse administered liquid Colace followed by crushed Urecholine mixed with water through the g-tube without flushing the tube in between the two medications. The nurse acknowledged the omission during an interview, and the Director of Subacute confirmed that this was a medication error and not in accordance with facility policy. Review of the facility's medication administration policy further supported the requirement to flush g-tubes with water between medications to ensure complete dosing and prevent complications.
Failure to Label Opened Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen. Specifically, during a kitchen tour, a large box of sausage, a large box of bacon, and a large open carton of eggs were found unsealed and without an open or use by date written on them inside a refrigerator. The Dietary Clerk confirmed that the cook is responsible for labeling these items and acknowledged that the boxes and carton were not labeled with an open or best by date. The Dietary Clerk also stated that without an open date, the facility would not know if the food is safe to serve. The Food and Nutrition Director stated that every food item received must have a received and best by date, and every food item opened must have an open date to prevent foodborne illnesses. A review of the facility's policy and procedure on food storage indicated that food should be stored in a safe and sanitary manner to prevent contamination and that items should be rotated so the oldest dates are used first. The failure to label these food items had the potential to result in harmful bacteria growth and cross contamination, affecting at least one medically compromised resident who receives food from the kitchen.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that the call light was within reach for two residents who were dependent on staff for all activities of daily living. For one resident with chronic respiratory failure, ventilator dependence, seizure disorder, and severely impaired cognition, the care plan specifically required the call light to be within reach at all times to prevent falls or injury. However, during an observation, the call light was found hanging on the wall at the head of the bed, out of the resident's reach, after staff had finished turning and repositioning the resident. Both a CNA and an LVN confirmed that the call light should have been placed within reach before leaving the room, and acknowledged that this was not done. A second resident, also dependent on staff for activities of daily living and with diagnoses including chronic respiratory failure, chronic encephalopathy, tracheostomy, cerebral palsy, and seizure disorder, was observed lying in bed with the call light behind the head of the bed and out of reach. The care plan for this resident also required the call light to be kept within reach at all times. A CNA confirmed during the observation that the call light was not accessible and should have been placed next to the resident. Interviews with nursing staff further confirmed that facility policy and procedure required call lights to be placed within reach of residents at all times, and that failure to do so could result in a delay in care. Review of the facility's policy reiterated the requirement to always place call cords within the resident's reach, which was not followed in these instances.
Delay in Physician Notification Following Change in Resident Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely notification of the attending physician following a significant change in condition for one resident. The resident, who had a history of chronic respiratory failure, seizure disorder, traumatic brain injury, and was in a vegetative state, developed a fever and increased thick, dark yellow secretions late in the evening. Nursing documentation indicated that these symptoms were observed at 11 p.m., but there was no record of the attending physician being notified at that time. The attending physician was eventually notified approximately six hours later, in the early morning, after the resident continued to exhibit symptoms including fever, increased secretions, excessive coughing, and vomiting. At that point, the physician provided new orders for diagnostic tests and treatments, including blood cultures, laboratory tests, intravenous fluids, and antibiotics. Both the registered nurse and the director of subacute care acknowledged during interviews that the delay in physician notification was not in accordance with facility policy and could result in delayed care. Facility policy required prompt notification of the physician in the event of an acute medical change, with documentation of all attempts to notify and follow-up actions. The nurse in charge was responsible for ensuring the physician and family or legal representative were notified prior to the end of the shift when a change in condition was noted. In this case, the delay in notification was confirmed through record review and staff interviews, constituting a failure to follow established procedures for timely communication regarding changes in a resident's condition.
Failure to Float Heels as Ordered for Pressure Injury Prevention
Penalty
Summary
Facility staff failed to follow physician orders and care plan interventions for a resident with a history of a deep tissue injury on the left heel. The resident, who was dependent on staff for all activities of daily living and had significant cognitive and physical impairments, had an order and care plan in place to float her heels on two pillows to prevent pressure injuries. During an observation, it was noted that the resident's heels were resting directly on the mattress, contrary to the prescribed intervention. A registered nurse confirmed during the observation that the resident's heels were not floated as required and acknowledged that the order to float the heels on two pillows was not followed by facility staff. The facility's policy on pressure ulcer management also indicated the use of appropriate pressure relief devices, which was not implemented in this instance.
Failure to Secure Bed Brakes for Dependent Resident
Penalty
Summary
Facility staff failed to ensure that the brakes were set on the hospital bed for one of four sampled residents during a random observation. The resident involved was admitted with multiple significant diagnoses, including chronic respiratory failure requiring a ventilator, chronic encephalopathy, and dementia. The resident was documented as being dependent on staff for activities of daily living and was rarely or never able to make decisions or provide meaningful information. During an observation, the resident was found lying in bed with the bed brakes unlocked and no staff present in the room. A registered nurse, upon noticing the unlocked brakes, acknowledged that this was dangerous and could cause a fall or injury. Review of the hospital bed's operations manual confirmed that brakes should always be applied when a resident is on the bed, and staff should ensure the brakes are locked by pushing on the bed after application.
Failure to Maintain Proper Catheter Tubing Positioning
Penalty
Summary
A resident who was dependent on staff for all activities of daily living and had multiple complex medical conditions, including chronic respiratory failure, chronic encephalopathy, tracheostomy, cerebral palsy, and seizure disorder, was observed with a deficiency in urinary catheter care. The resident's care plan specifically required staff to ensure that the urinary catheter tubing was not kinked and that urine could flow freely at all times to prevent infection. During an observation, the resident was found in bed with the urinary catheter tubing hanging below the bed and forming a large loop, which contained yellow liquid with sediment. A registered nurse confirmed that the tubing was looped and that urine was not draining properly, acknowledging that the tubing should be straight to allow for proper drainage. Review of the facility's catheter care policy also indicated the need to keep tubing free of kinks and obstructions. This failure to maintain proper catheter tubing positioning constituted a deficiency in providing appropriate care to prevent urinary tract infections.
Failure to Label TPN Bag and Tubing per Protocol
Penalty
Summary
Facility staff failed to administer total parenteral nutrition (TPN) in accordance with professional standards of practice for one resident. Specifically, the TPN bag and the peripherally inserted central catheter (PICC) line tubing were not labeled with the date and time they were started. This was observed during a random screening, and the omission was confirmed by a registered nurse, who acknowledged that facility policy requires all TPN bags, medications, and tubing to be labeled with the date and time to ensure proper tracking and reduce confusion among nursing staff. The resident involved had multiple complex medical conditions, including chronic respiratory failure, chronic encephalopathy, tracheostomy, cerebral palsy, and seizure disorder. The resident was dependent on staff for all activities of daily living and was rarely or never able to communicate or make decisions. The care plan for this resident included an intervention to change tubing according to protocol, but this protocol was not followed as evidenced by the lack of labeling on the TPN bag and tubing.
Failure to Label Yankauer Suction Catheter with Change Date
Penalty
Summary
A deficiency was identified when a resident who was ventilator-dependent and required frequent suctioning did not have their Yankauer suction catheter properly labeled with the date it was to be changed next. The resident had a history of respiratory failure, severe cognitive impairment, and required total assistance with all activities of daily living. Physician's orders and the care plan specified suctioning every two hours and as needed, with interventions to minimize infection risk, including regular equipment changes and labeling. During observation, the resident's Yankauer suction catheter was found inside an opened storage bag without a label indicating the date it was to be changed. Interviews with nursing staff and the Director of Sub Acute confirmed that facility policy required daily changes of respiratory equipment, with labeling to indicate the next change date and staff initials. The absence of this label meant staff could not verify when the catheter was last changed, which was inconsistent with professional standards and facility policy, and placed the resident at risk for infection from potentially contaminated equipment.
Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with chronic respiratory failure, ventilator dependence, and dysphagia with a gastrostomy tube, there was a discrepancy between the written physician's order and the electronic order for docusate sodium. The written order specified docusate sodium soft gel capsules to be administered via g-tube, while the electronic order listed the medication in liquid form. Observation confirmed that the liquid form was administered, and staff interviews revealed that the order should have been clarified with the physician to ensure consistency and accuracy in the resident's medical record. For another resident with acute hypoxic respiratory failure, tracheostomy, and sepsis, the medical record was inaccurate when a nurse documented the presence of bleeding and still administered Eliquis, an anticoagulant. The care plan for this resident included monitoring for signs of bleeding and holding anticoagulant therapy if bleeding was observed. Review of the Medication Administration Record showed that Eliquis was given despite documentation of bleeding, and staff interviews confirmed that the medication should have been held under these circumstances. These failures resulted in medical records containing inaccurate documentation, with discrepancies between physician orders and actual care provided. The facility's policy required accurate, factual, and specific documentation of resident conditions and interventions, which was not followed in these instances.
Failure to Monitor and Document Antibiotic Use and Surveillance
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy for two residents by not adequately monitoring antibiotic use, side effects, or adverse reactions, and by failing to maintain complete infection control surveillance records. For one resident, who was admitted with multiple complex diagnoses including seizure disorder, traumatic brain injury, respiratory failure with tracheostomy, and was in a vegetative state, there was a documented fever and increased secretions, leading to the initiation of intravenous antibiotics (Zosyn and Vancomycin). Despite care plan interventions requiring observation for adverse reactions, there was no documentation in the nurses' notes of monitoring for antibiotic use or adverse reactions during the course of treatment. Interviews with facility staff, including the MDS nurse, Infection Preventionist, and pharmacist, confirmed that the expectation was for nurses to monitor and document antibiotic use and any side effects or adverse reactions every shift. However, this monitoring and documentation did not occur as required. The pharmacist also relied on these notes for their own monitoring, further highlighting the gap in the process. For another resident, who was also in a vegetative state and dependent on staff for all activities of daily living, the facility failed to complete the Infection Control Log related to antibiotic use for a wound infection. Key information such as date of admission, signs and symptoms, organism, and date infection resolved were missing from the log. Staff interviews confirmed that the log was incomplete and that the responsibility for documentation was not consistently followed. The facility's policy required antibiotic surveillance as part of its stewardship program, but this was not carried out as documented.
Inadequate Infection Preventionist Oversight and Incomplete Antibiotic Surveillance
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was qualified and competent in implementing the infection prevention and control program. Specifically, the IP did not monitor antibiotic use, side effects, or adverse reactions for a resident who was prescribed Zosyn and Vancomycin for a fever. Despite care plan interventions requiring observation for adverse reactions, there was no documented monitoring in the nurse's notes for the duration of the antibiotic therapy. Additionally, the facility's Infection Control Surveillance Log for another resident receiving antibiotics for a wound infection was incomplete. Key information such as date of admission, signs and symptoms, organism location, and date infection resolved were missing from the log. Both the Minimum Data Set Nurse and a Registered Nurse confirmed that the log was incomplete for this resident. Interviews with the IP revealed that she had not started her own antibiotic surveillance log as required by her job description, and she acknowledged that the antibiotic surveillance process was not being completed. The IP also stated that she was responsible for multiple facilities and had not attended required training or conventions. The Director of Subacute and Chief Nursing Officer confirmed that the IP had not met the qualifications outlined in her job description and that the infection control tracking and monitoring duties were not being fulfilled.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and implement a policy and procedure on enhanced barrier precautions (EBP) designed to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes. This deficiency was observed in four sampled residents during medication administration. The facility did not have EBP signs or isolation carts at the entrance of the residents' rooms, and staff did not don appropriate personal protective equipment (PPE) such as gowns during high-contact resident care activities. This failure was confirmed through observations, interviews, and record reviews involving Residents 10, 13, 12, and 14, all of whom had conditions that made them prone to infections, such as tracheostomies, g-tubes, and open wounds. Resident 10 was admitted with diagnoses including chronic respiratory failure, enterocolitis due to clostridium difficile, and tracheostomy status. The resident was on isolation for an active infectious disease and required various medical interventions. During medication administration, the nurse did not follow EBP protocols, such as wearing a gown, despite the resident's high risk of infection. The Nurse Manager and Infection Preventionist acknowledged the lack of EBP implementation and the absence of staff training on the procedure. Similarly, Resident 13, who had chronic respiratory failure, tracheostomy status, and g-tube status, did not have EBP signs or isolation carts in their room. The nurse administering medications did not wear a gown, and the Nurse Manager confirmed that EBP should have been implemented. Resident 12 and Resident 14, both with tracheostomies and g-tubes, also did not have EBP protocols followed during medication administration. Interviews with the Nurse Manager, Infection Preventionist, and Chief Nursing Officer revealed that the facility was aware of the need for EBP but had not yet developed or implemented the necessary policies and procedures.
Failure to Rotate Injection Sites for Medications
Penalty
Summary
The facility failed to provide care in accordance with professional standards to three residents by not rotating subcutaneous injection sites for medications. Resident 7, who had diagnoses including hemiplegia, anoxic brain damage, and circulatory system diseases, received repeated heparin injections in the same areas, leading to potential risks of bruising and bleeding. The Medication Administration Record showed that injections were not rotated on multiple dates, and this was confirmed by the Minimum Data Set Coordinator-Registered Nurse (MDSC-RN) and the Nurse Manager (NM). The facility's policy and prescribing information for heparin also indicated the need for site rotation to prevent such issues. Resident 9, diagnosed with anemia, coronary artery disease, and in a persistent vegetative state, also received repeated enoxaparin sodium (Lovenox) injections in the same areas. The MDSC-RN verified that the injection sites were not rotated on several dates, which was corroborated by the Pharmacist (PHARM 1) and the NM. The facility's policy and the prescribing information for enoxaparin sodium highlighted the importance of alternating injection sites to prevent complications. Resident 13, who had diabetes mellitus, malnutrition, and dysphagia, received repeated Lantus insulin injections in the same areas. The MDSC-RN confirmed that the injection sites were not rotated on numerous dates, and this was supported by PHARM 1 and the NM. The facility's policy and the prescribing information for Lantus emphasized the need for site rotation to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to act upon the recommendations of the consultant pharmacist for two of five sampled residents. For Resident 2, the facility did not taper down the dosage of methadone as recommended by the pharmacist. Despite the pharmacist's recommendation to reduce the dosage to 10 mg every 24 hours, the physician continued the existing pain management regimen without documenting the rationale for not following the recommendation. The pharmacist also failed to document her conversation with the physician regarding the recommendation, leaving the healthcare team unaware of the rationale for not tapering the medication. For Resident 17, the facility did not document episodes of respiratory distress or heart rate greater than 120 in the electronic medication administration record (eMAR) when administering lorazepam. The medication was administered on multiple occasions without documented evidence of the required conditions being met. This lack of documentation prevented the care team from assessing the necessity of the medication and ensuring it was used appropriately. For Resident 7, the facility did not act upon the pharmacist's recommendation to consider discontinuing Robitussin if it was not being used. The medication order remained active without a stop date, and there was no documentation indicating that the recommendation was communicated to the physician or acted upon. This oversight could lead to the resident receiving unnecessary medication and potential side effects from prolonged use of Robitussin.
Failure to Rotate Injection Sites for Medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors by not rotating subcutaneous injection sites for three residents. Resident 7, who had diagnoses including hemiplegia, anoxic brain damage, and circulatory system diseases, received repeated heparin injections in the same areas, leading to potential bruising and bleeding. The Medication Administration Record showed multiple instances where the injection sites were not rotated as required, which was confirmed by the Minimum Data Set Coordinator-Registered Nurse (MDSC-RN) and the Nurse Manager (NM). Both acknowledged that not rotating the injection sites is considered a medication error. Resident 9, diagnosed with anemia, coronary artery disease, and in a persistent vegetative state, also received repeated enoxaparin sodium (Lovenox) injections in the same areas. The MDSC-RN verified that the injection sites were not rotated, and this was confirmed by both the pharmacist and the NM. The facility's policy and the prescribing information for enoxaparin sodium both indicated the necessity of rotating injection sites to prevent adverse effects. Resident 13, who had diabetes mellitus, malnutrition, and dysphagia, received repeated Lantus insulin injections in the same areas. The MDSC-RN confirmed that the injection sites were not rotated, and this was corroborated by the pharmacist and the NM. The facility's policy and the prescribing information for Lantus emphasized the importance of rotating injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. The failure to rotate injection sites for these residents was identified as a significant medication error by the surveyors.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation and interview with the Director of Food and Nutrition (DFN), it was noted that the ice scooper was stored in an uncovered holder mounted on the side of the machine. The DFN acknowledged that the ice scooper should be stored in a closed container to prevent outside contaminants from settling in the scooper, which could cause foodborne illnesses. Additionally, Food Service Worker 1 (FSW 1) was observed not wearing a hairnet while inside the kitchen. The DFN confirmed that FSW 1 should wear a hairnet at all times when working in the kitchen to prevent hair from contaminating food and equipment, which could result in serving contaminated food to residents. Furthermore, an opened container of canola/extra virgin olive oil was found without an open date label. The DFN stated that the container should have an open date label to inform kitchen staff when to discard the oil. The absence of this label could potentially result in staff using expired oil, leading to foodborne illnesses among residents. The facility's policies and procedures, including those for dispensing ice, dress code, and food labeling and dating, were reviewed and found to support the need for these practices to prevent contamination and ensure food safety.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to several deficiencies. Firstly, the barcode scanner used during medication administration was not sanitized before and after use, potentially causing cross-contamination between residents. This was observed during medication administration for two residents, where the Licensed Vocational Nurse (LVN) did not clean the scanner after placing it on a resident's tablet and before using it on another resident. The Nurse Manager confirmed that the barcode scanners should be disinfected between uses to prevent the spread of infections, but this practice was not followed by the LVN. Secondly, the facility did not implement Enhanced Barrier Precautions (EBP) during gastrostomy tube medication administration for residents with indwelling devices. The LVN administered medications to residents without donning an isolation gown, despite the residents having conditions that made them prone to infections. Both the Nurse Manager and the Infection Preventionist acknowledged that EBPs should be used for residents with wounds or indwelling devices, but the facility had not implemented this practice. The Chief Nursing Officer also confirmed that the EBP policy was not finalized or implemented, despite being aware of its importance. Lastly, the facility failed to discard opened and partially used normal saline solution unit dose vials after use. During an observation, two opened vials were found inside a box, which were supposed to be single-use only. Both a Registered Nurse and a Respiratory Therapist confirmed that these vials should have been discarded after use to prevent infection. The facility's policy also indicated that single-use items should be discarded after use, but this was not adhered to, posing a risk of infection to the residents.
Failure to Implement Enhanced Barrier Precaution Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan on enhanced barrier precaution isolation for two residents, leading to potential infection control issues. Resident 10, admitted with chronic respiratory failure, enterocolitis due to clostridium difficile, and tracheostomy status, did not have an enhanced barrier precaution sign or isolation cart outside their room. During medication administration, the Licensed Vocational Nurse (LVN) did not wear a gown, and it was confirmed that Resident 10's care plan did not include enhanced barrier precautions, which was acknowledged as important by both the LVN and the Nurse Manager (NM). Similarly, Resident 13, admitted with chronic respiratory failure, tracheostomy status, and gastrostomy status, also lacked an enhanced barrier precaution sign and isolation cart outside their room. The same LVN did not wear a gown during medication administration for Resident 13, and it was confirmed that Resident 13's care plan did not address enhanced barrier precautions. The facility's policy required a comprehensive care plan to be developed within seven days of admission and updated regularly, but this was not followed for these residents. The observations and interviews revealed that the facility did not adhere to its own care planning policies, which required the development of a coordinated and comprehensive written plan based on the resident assessment and individual needs. This failure to implement appropriate infection control measures had the potential to spread infection among residents and staff, as evidenced by the lack of enhanced barrier precaution care plans for Residents 10 and 13.
Failure to Prevent Accidents Due to Unattended Medication
Penalty
Summary
The facility failed to ensure residents received adequate supervision to prevent accidents by leaving a medication cup containing clear and white ointment unattended and readily accessible in a shared room. This incident involved two residents, one of whom was in a persistent vegetative state and totally dependent on staff for all activities of daily living, while the other resident was sometimes able to make himself understood and also totally dependent on staff for mobility and hygiene. Both residents had physician orders for the application of ointments for skin management and maintenance, which were not properly administered and monitored by the staff. During an observation, a Certified Nursing Assistant (CNA) found a medication cup with ointments on a wall-mounted workstation in the shared room of the two residents. The CNA did not know who placed the cup there and stated that ointments should be discarded after each use and not left in residents' rooms. Further interviews with a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN) confirmed that the medication cup was not labeled, and it was against facility policy to leave medications in residents' rooms due to the risk of accidental ingestion. The Nurse Manager reviewed the facility's policy and procedure regarding medication administration, which indicated that medications should not be left with residents to self-administer unobserved. The policy was not followed in this instance, leading to a potential risk for the residents. The facility's failure to adhere to its medication administration policy resulted in a deficiency that could have caused harm to the residents involved.
Failure to Administer and Document IV Fluids Properly
Penalty
Summary
The facility failed to administer parenteral fluids consistent with professional standards of practice for two residents. For Resident 1, the facility did not label the midline catheter dressing with the date of the last dressing change. This was observed during a bedside check, and the registered nurse confirmed the omission. The facility's policy requires midline catheter dressings to be changed every seven days and as needed, and the absence of a date on the dressing could lead to untimely changes and potential infection. The resident had severe cognitive impairment and required total assistance with all activities of daily living, making proper catheter care crucial. For Resident 2, the facility failed to document midline catheter care and dressing changes as per the facility's policy. The resident's midline catheter dressing was observed to be dated, but there was no documented evidence of the dressing change in the nursing records. Additionally, there was no documentation of midline catheter care for specific shifts. The registered nurse verified these documentation gaps, which are against the facility's policy that mandates documenting all assessments and interventions. Resident 2 had intact cognition but required total assistance with all activities of daily living, and proper documentation is essential to ensure timely and appropriate care. Both residents had physician's orders for midline catheter care, including dressing changes every seven days and flushing with normal saline every shift. The facility's failure to adhere to these orders and document the care provided placed the residents at risk for complications such as infection. The facility's policies on midline catheter management and charting guidelines were not followed, leading to these deficiencies.
Failure to Ensure Proper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure safe provision of pharmaceutical services during an inspection of Medication Cart 2. An opened and unlabeled single-use vitamin A&D ointment packet was found in the top drawer of the cart. The Licensed Vocational Nurse (LVN) present during the inspection stated that the ointment packet should have been discarded after use in the resident's room. The LVN did not know which resident the packet was opened for or if it had been used, indicating a lapse in proper medication handling procedures. The Nurse Manager confirmed that such ointment packets are not meant for multiple residents and should be labeled with the resident's name if unused and opened in the medication cart. A review of the facility's policies indicated that drugs and devices should be stored to ensure stability and integrity, and that all medications must be appropriately labeled to promote safety. The facility's policy on medication storage and labeling was not followed, as evidenced by the presence of the opened and unlabeled ointment packet. This failure had the potential to result in cross contamination and decreased efficacy of the medication, posing a risk to resident safety.
Failure to Maintain Nebulizer Compressor
Penalty
Summary
The facility failed to maintain a handheld nebulizer compressor in safe operational condition for a resident in a persistent vegetative state. The nebulizer compressor, which was essential for administering respiratory treatments, was labeled with a next inspection due date of July 2023 but had not been inspected by the time of the survey in April 2024. This oversight was identified during an observation of the resident's environment and confirmed through interviews with nursing and respiratory therapy staff, who acknowledged the lapse in inspection and maintenance protocols. The resident, who was totally dependent on staff for all activities of daily living, had multiple physician orders for routine and as-needed nebulizer treatments to manage respiratory conditions. Despite these orders, the nebulizer compressor had not been inspected as required, potentially compromising the effectiveness of the resident's respiratory care. Staff interviews revealed a lack of clarity regarding the responsibility for ensuring the equipment was inspected, with both nursing and respiratory therapy staff assuming the other party would handle it. Further investigation with the Biomed Engineering Site Lead revealed that the nebulizer had been placed in out-of-service status because it had not been located for inspection. The facility's Environment of Care Manual indicated that medical equipment should be inspected, tested, and maintained regularly, but this protocol was not followed in this case. The failure to inspect the nebulizer compressor as scheduled was attributed to an oversight and a breakdown in communication among staff responsible for the equipment's maintenance.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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