South Pasadena Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in South Pasadena, California.
- Location
- 904 Mission St, South Pasadena, California 91030
- CMS Provider Number
- 555908
- Inspections on file
- 40
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 58
Citation history
Health deficiencies cited at South Pasadena Care Center during CMS and state inspections, most recent first.
A resident with leukemia and prostate cancer, cognitively impaired and needing partial assistance with ADLs, had a PRN order for O2 via NC or mask to maintain SpO2 ≥ 92%, with a requirement to record saturation before administration. On one occasion, the resident was found unresponsive and an LVN administered O2 at 10 L/min via mask, but this intervention and the required O2 saturation were not documented on the MAR or the SBAR communication form. This omission occurred despite a facility policy requiring that all services provided and changes in condition be recorded in the medical record to support team communication.
A resident with paraplegia, a stage 4 sacral pressure ulcer, and osteomyelitis experienced a witnessed fall during a transfer, landing with both knees on the floor and striking a foot on the wheelchair footrest. Staff obtained X‑ray orders for the foot and hips/pelvis, but not the knees. Over the next day, the resident reported knee swelling, warmth, and a burning sensation to CNAs and an LVN, and a family member later observed swollen knees and was told only back and foot X‑rays had been done. The LVN assumed the existing X‑ray orders covered the whole leg and did not notify the physician of the new knee complaints, and no specific knee X‑ray was ordered until later. The DON confirmed that policy required licensed nurses to assess and notify the physician of such changes in condition and that the facility’s change-in-condition policy required notification of the physician and representative after accidents with potential need for physician intervention.
A resident with paraplegia, bilateral lower extremity impairment, and multiple stage 4 pressure ulcers to the sacrococcyx, ischium, and hip had care plans and facility policy requiring turning and repositioning q2h to protect skin integrity. Observations found the resident lying on his back in bed, and the resident reported staff had not offered or assisted with repositioning. A CNA admitted the resident could not move his legs, required staff to carry and align a leg brace during turns, was supposed to be repositioned q2h, but was only repositioned once during an 8‑hour shift with no other staff assisting. The DOR and DON confirmed the resident’s dependence on staff for repositioning and the requirement to provide q2h positioning per care plan and policy, which was not implemented.
The facility failed to maintain a safe environment when smoke from a burnt HVAC unit filter entered an interior hallway after roofing workers used a torch that ignited the HVAC filter. Multiple staff, including the DON, LVNs, CNA, Activity Director, maintenance staff, and the receptionist, reported smelling something burning, seeing haze or smoke in the hallway, and noting that the smoke detector did not alarm. Maintenance traced the source to an HVAC unit above the hallway, and the ADM confirmed the filter was partially burnt and that smoke had traveled down the vent into the building. Staff closed residents’ doors and paramedics on-site for a resident’s change of condition assisted by opening the front door and using fans, while the facility’s own policy required a safe and secure environment for staff and residents.
A resident with non-Hodgkin lymphoma, end stage renal disease, and heart failure did not receive a scheduled oncology appointment due to insurance issues. Facility staff did not notify the primary care physician or reschedule the appointment, resulting in the resident not receiving an evaluation and treatment plan for cancer, contrary to facility policy.
A facility allowed a family member to remotely control a tablet camera in a shared room, resulting in continuous video and audio monitoring of three residents, including during personal care activities. Residents and staff reported discomfort, loss of privacy, and concerns about unauthorized disclosure of medical information. Facility policies requiring privacy and care planning for device use were not followed, and the situation was acknowledged by the DON as invasive.
A resident with multiple chronic conditions and severe cognitive impairment experienced ongoing generalized itching, with visible scratch marks and skin irritation. Despite repeated complaints and observations by staff, an LVN did not promptly notify the physician or provide treatment, and no care plan was developed to address the issue, contrary to facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident experienced a significant medication error due to a failure in the medication administration process.
Two residents with significant physical and cognitive impairments were found to have their call devices out of reach—one with hand contractures had the call pad hanging below the bed, and another with severe cognitive impairment had the call pad on the floor. Staff confirmed that the devices were not accessible as required by facility policy, which states call lights must be within easy reach for residents needing assistance.
Two residents receiving IV therapy did not receive care in accordance with facility policy: one had unlabeled IV tubing, and another did not have required shift-by-shift IV site monitoring and documentation by nursing staff. These failures were confirmed through observation, staff interviews, and record review.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, and serve food according to professional standards, resulting in a deficiency related to food safety and handling.
Two dumpsters were found with lids not completely closed, leaving garbage and refuse exposed to the environment. The Maintenance Supervisor confirmed this was against facility policy, which requires dumpster lids to remain closed to prevent pest access.
Two residents with severe cognitive and physical impairments did not have properly coordinated or documented hospice care, as required by physician orders and facility policy. Hospice visit calendars and sign-in sheets were incomplete or missing, and staff could not confirm that scheduled visits by RNs, LVNs, or NAs occurred. Facility staff and the DON acknowledged the lack of required documentation and communication with hospice providers, resulting in a failure to ensure that hospice services were delivered as ordered.
A deficiency was identified when an LVN disposed of blood-soiled dressings from a resident's sacral wound in a clear plastic bag and black bin, rather than using red bags as required by facility policy. The Infection Prevention Nurse confirmed that the facility did not have color-coded bins for hazardous waste, and that the disposal practice did not follow the written procedures for handling items contaminated with blood.
Lint was found in a dryer lint trap and laundry logs were incomplete or inaccurately documented, with a future-dated water temperature entry. Additionally, urine was observed on a toilet seat riser chair and floor in a resident's room and restroom, with staff confirming these conditions were unsanitary and not in line with facility policy.
A resident with dementia, Parkinson's disease, and quadriplegia was assisted with eating by a CNA who stood above the resident's eye level, rather than sitting or adjusting the bed to maintain eye contact, as required by facility policy. Staff interviews confirmed that this practice does not respect resident dignity, and the RN present did not correct the CNA's actions.
A resident with multiple chronic conditions was found to have a bed sheet with over thirty small holes, leading to discomfort and dissatisfaction. Staff confirmed that such damaged linen is not consistent with a homelike environment and acknowledged the issue, which was observed during a survey.
A resident with dementia, depression, and anxiety disorder was prescribed PRN Lorazepam for anxiety for 30 days without a documented rationale for extending use beyond the facility's 14-day policy limit. Staff interviews and record reviews confirmed that the required psychiatric documentation was missing, resulting in non-compliance with facility policy regarding psychotropic medication orders.
Three residents did not have individualized care plans developed for their specific clinical needs, including a fluid restriction for a resident with ESRD, IV antibiotic administration for a resident with a surgical wound infection, and the use of a bolster low air loss mattress for a resident at risk for pressure ulcers. Staff and nursing leadership confirmed that these care plans were missing, despite physician orders and ongoing interventions.
A resident with a sacral pressure ulcer and limited mobility was provided with a bolster low air loss mattress to prevent falls and pressure injuries, but staff failed to obtain a physician's order for this specific equipment. Nursing staff and the DON confirmed the mattress was in use based on interdisciplinary team decisions, yet documentation and facility policy did not reflect this practice.
A resident with a GTube, dependent on tube feeding and with severely impaired cognitive skills, was observed receiving only 5 cc of water flush after medication administration, instead of the physician-ordered 30-50 cc. The LVN acknowledged not following the order, and the facility's policy required adherence to prescribed enteral nutrition protocols.
A resident with ESRD and heart failure, receiving dialysis and under a physician-ordered fluid restriction, did not have their daily fluid intake monitored or documented as required. Nursing staff failed to record intake amounts on the MAR or elsewhere, and the resident's chart lacked any intake documentation for an extended period, despite facility policy and physician orders mandating such monitoring.
Staff failed to consistently and accurately document shift-to-shift narcotic counts for controlled medications, leaving multiple blank entries on required forms for several medication carts. This incomplete documentation was confirmed by interviews with nursing staff and the DON, and affected a resident with severe cognitive impairment and complex medical needs, resulting in an inability to ensure proper accounting and administration of controlled substances.
A resident with a GTube and complex medical needs did not receive the prescribed amount of water flush between medications, as an LVN administered only 5 cc instead of the ordered 10-15 cc between each medication. This resulted in three medication errors out of 25 observed opportunities, causing the facility's medication error rate to exceed the 5% threshold. The care plan, physician's orders, and facility policy all required the correct water flush amount, which was not followed.
A resident with diabetes and multiple care needs was tested for blood sugar using expired glucose test strips by an LVN, despite facility policy requiring current supplies. The DON confirmed that expired strips should not be used, and the facility's procedures mandate checking expiration dates before use.
Two residents experienced deficiencies in medical record documentation, including missing and inaccurate entries for IV therapy and G-tube water flushes. In one case, a resident's IV site checks were not documented for several days, and a nurse recorded an IV flush after the IV had been removed. In another case, a resident did not receive the ordered water flushes with medications, and the MAR was inaccurately completed by a nurse who did not perform the task. Facility policy requires accurate and complete documentation, which was not followed in these instances.
The facility did not post current nurse staffing information in a visible location, with outdated data remaining displayed for several days. Staff interviews revealed confusion over responsibility for daily postings, resulting in a lack of up-to-date staffing information accessible to residents and visitors, contrary to facility policy.
A resident who required substantial assistance with bathing and dressing due to muscle weakness and diabetes was taken from the shower room with only the front of their body covered, leaving the sides and back exposed. The CNA involved acknowledged the lapse, and the DON confirmed that full coverage with a poncho was required. The resident reported feeling disrespected, and facility policy mandated shielding residents during personal care to maintain dignity and privacy.
A resident reported to an RN that another resident physically assaulted him, but the incident was not reported to the State Agency, ombudsman, or law enforcement within the required two-hour window. Both residents, one with muscle weakness and diabetes and the other with schizophrenia and insomnia, remained in the same room for nearly six hours after the allegation, contrary to facility policy requiring immediate separation during abuse investigations.
A resident dependent on gastrostomy tube feeding for nutrition and hydration did not receive the prescribed volume of enteral feeding due to staff failure to restart the feeding at the scheduled time. The resident, with a history of malnutrition, pressure ulcer, and stroke with dysphagia, was observed to have their tube feeding off when it should have been running, and the LVN confirmed forgetting to turn it back on as ordered.
A resident with multiple chronic conditions and moderate cognitive impairment was unable to sleep due to a roommate's loud television volume, leading to a verbal confrontation. Staff interviews confirmed that the television should have been kept at a comfortable level during quiet hours, but this was not done, violating the resident's right to dignity and comfort as outlined in facility policy.
The facility failed to provide two residents with written information regarding their right to formulate an advance directive. Resident 16, with intact cognitive skills, and Resident 286, with severely impaired cognitive skills, both lacked the necessary documentation in their medical records. The absence of advance directive acknowledgment forms was confirmed by the Admission Coordinator and Social Services Director, despite facility policy requiring such information to be provided upon admission.
Two residents with severe cognitive and physical impairments did not receive necessary grooming care, as their long fingernails were not trimmed by staff, contrary to facility policy. Observations and interviews revealed that CNAs failed to document refusals of care, and the facility did not adhere to its procedures for maintaining residents' hygiene.
The facility failed to pad side rails for three residents with seizure disorders, despite physician orders and care plans requiring this precaution. Observations showed unpadded side rails, and staff confirmed the necessity of padding to prevent injury during seizures.
The facility failed to provide necessary care for two residents, leading to potential health risks. A resident with a Foley catheter was not monitored as per the physician's order, with missing documentation indicating lapses in care. Another resident with a suprapubic stoma had a dressing that was not changed daily, contrary to the physician's order, increasing the risk of infection. These deficiencies highlight failures in adhering to care plans and documentation protocols.
The facility failed to follow its policy on oxygen administration for two residents. One resident received oxygen at a higher rate than ordered, while another had an unlabeled nasal cannula and a dirty oxygen concentrator. Staff confirmed these discrepancies, highlighting lapses in following physician orders and infection control practices.
The facility failed to properly seal food containers and maintain cleanliness in a refrigerator designated for residents' food, as observed by the Dietary Supervisor and Infection Preventionist. This non-compliance with the facility's food safety policies posed a risk of food contamination and potential illness for residents.
The facility failed to accommodate the needs of two residents, leading to potential safety risks. A resident with Parkinson's disease struggled with a low toilet seat, which was not adjusted despite staff awareness. Another resident with hemiplegia was unable to reach his call light due to improper placement, despite being dependent on assistance. These issues violated facility policies on accommodating resident needs and ensuring call light accessibility.
A resident with severe cognitive impairment and mobility issues was found to have fecal matter on the floor next to their bed, which was not cleaned promptly, posing an infection control concern. The facility's policies on maintaining a clean and homelike environment were not followed, as noted by the Infection Prevention Nurse and Director of Nursing.
The facility failed to implement a care plan for a resident with epilepsy by not using padded side rails as ordered, and did not develop a care plan for another resident's suprapubic stoma site care. Observations showed the side rails were not padded, and the stoma site was not cleaned or dressed as required, contrary to physician orders and facility policy.
A resident with aphasia and other conditions was not provided with a communication board in their language, as required by their care plan. Despite the facility's policy to ensure communication in a language the resident understands, the board was missing from the resident's room, potentially delaying care.
The facility failed to ensure correct settings for low air loss mattresses for two residents, one with existing pressure ulcers and another at high risk for skin breakdown. Observations showed the mattresses were set higher than the residents' weights, contrary to physician orders and facility policy, potentially affecting wound healing and ulcer prevention.
A resident with generalized weakness and neuromuscular dysfunction did not receive ordered RNA services for range of motion exercises, as there was no documentation of these services being performed. Despite a physician's order for RNA services to start, interviews confirmed the absence of records, indicating non-compliance with the facility's policy. The resident expressed concerns about losing physical function, highlighting the importance of RNA services in maintaining joint function.
A resident with chronic kidney disease was not provided the required two liters of water daily as per physician's orders. The care plan lacked interventions for hydration, and staff were unaware of the resident's fluid needs. Observations showed the resident was often thirsty, with no cups available for drinking. The facility's documentation did not accurately record fluid intake, contrary to its hydration policy.
A resident with Parkinson's disease did not have their heart rate checked before receiving metoprolol, contrary to the physician's order. The LVN administering the medication failed to follow the order, which required withholding the drug if the pulse was below 60. This oversight was confirmed by the MDS nurse and DON, highlighting a lapse in adhering to prescribed medication protocols.
A resident admitted with generalized weakness and neuromuscular dysfunction of the bladder did not have RNA services documented as required. Despite an order for RNA services to begin, there was no log of services provided. RNA 2 admitted to signing the log retrospectively, and the Director of Rehab confirmed that missing documentation indicates services were not performed. The Director of Nursing stressed the need for immediate documentation to ensure accuracy, as per facility policy.
A resident admitted to hospice care in an LTC facility did not receive a comprehensive assessment for the plan of care, including the frequency of hospice staff visits. Despite being placed on hospice care, there were no physician orders or hospice calendar entries indicating the frequency of visits. The resident received hospice visits on only two occasions, with no visits documented for several days. The facility's policy required hospice services to be provided upon physician order, and the agreement with the hospice required collaboration and documentation of care.
Two residents were affected by infection control deficiencies in a facility. An LVN failed to disinfect a shared blood pressure cuff after use on a resident with a history of UTI, risking cross-contamination. Another LVN did not wear PPE while administering medication to a resident with a gastrostomy tube on Enhanced Barrier Precautions, and mishandled the tube connection, risking infection. Facility policies on disinfection and aseptic techniques were not followed.
Failure to Document PRN Oxygen Administration and Assessment
Penalty
Summary
The deficiency involves the facility’s failure to accurately and completely document the administration of oxygen therapy and related assessments for one resident, as required by facility policy and professional standards. The resident was admitted with chronic lymphocytic leukemia of B-cell type not in remission and malignant neoplasm of the prostate, and was assessed on the MDS as cognitively impaired with a need for partial/moderate assistance for oral, toilet, and personal hygiene. The resident had an order, dated 1/23/2026, for oxygen at 2–4 L/min via nasal cannula or 5–10 L/min via mask to maintain O2 saturation ≥ 92%, with a requirement to record O2 saturation before administration. On the date of the incident, the MAR for the resident showed the PRN oxygen order but was blank for any oxygen administration on that day, and the SBAR communication form completed that afternoon did not indicate that oxygen had been given when the resident was found unresponsive. During a concurrent review of the MAR and SBAR, the LVN reported that at approximately 3:30 PM he administered oxygen at 10 L/min via mask to the resident upon finding him unresponsive but forgot to document this on both the MAR and the SBAR, and also did not record the O2 saturation as required. The facility’s Charting and Documentation policy stated that all services provided and any changes in the resident’s condition must be documented in the medical record to facilitate communication among the interdisciplinary team, which was not followed in this instance.
Failure to Notify Physician of Resident’s Post-Fall Knee Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to follow its "Changes in Resident Condition" policy by not notifying the physician when a resident reported altered knee sensation after a witnessed fall. The resident, who had diagnoses including paraplegia, a stage 4 sacral pressure ulcer, and osteomyelitis, was cognitively intact and required assistance with mobility. On the date of the fall, an SBAR documented that the resident experienced an unavoidable witnessed fall during a transfer, slipping from a CNA’s grasp and striking the left foot on the wheelchair footrest. An order was obtained for X‑rays of the left foot, second toe, and bilateral hips/pelvis, but no knee X‑ray was ordered at that time. In the days following the fall, the resident and family reported symptoms involving the knees that were not promptly communicated to the physician. The family member stated that when visiting about two days after the fall, the resident’s knees were very swollen, and the resident reported hearing a crack at the time of the fall and feeling a hot burning sensation in the knees for two days. The family member reported that when asking a nurse about X‑rays, the nurse said X‑rays had been done on the back and foot, and the family member then requested staff to contact the physician for a knee X‑ray. The resident stated that he landed on both knees, heard a crack, and that about an hour after the fall his right leg became swollen and warm, and by the next morning he felt a burning sensation in his legs, which he reported to two CNAs and an LVN. Staff interviews and record review confirmed that the physician was not notified of the resident’s new knee symptoms as required by policy. CNAs described seeing the resident with both knees on the floor and feet under the wheelchair, and one CNA observed redness of the upper shins after the fall. An LVN who worked the day after the fall stated the resident reported his knees did not feel normal and did not want his legs moved; the LVN reviewed the orders, saw an existing X‑ray order for the foot and hips/pelvis, and assumed it covered the whole leg. The LVN acknowledged that there was no specific knee X‑ray order and that she should have messaged the physician about the resident’s knee complaints. The DON stated that licensed nurses were required to assess and notify the physician of changes in condition, including when the resident reported burning sensations in the knees, and that the facility’s policy required notifying the resident, physician, and representative when an accident results in injury and has potential to require physician intervention.
Plan Of Correction
F580 How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 02/09/2026 Resident 1's attending physician was notified of residents complain of “burning sensation and pain on both knees” with orders for X-Ray on both knees. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. From 02/26/2026 thru 02/27/2026 The Director of Nurses (DON) and Quality Assurance Nurse (QAN) conducted an audit of all residents who experienced a fall, injury, or change in condition within the last 30 days to ensure timely physician notification occurred in accordance with the facility's policy and procedure titled "Changes in Resident Condition"; no otherresidents were identified to have been affected bythis deficient practice.What measures will be put into place or whatsystemic changes will the facility make to ensurethat the deficient practice does not recur. On 02/27/2026 DON re-educated all licensednursing staff (LVNs and RNs) on the facility'spolicy and procedure titled "Changes in ResidentCondition", with specific emphasis on: therequirement to notify the attending physicianimmediately upon any change in condition,including new or altered pain, swelling, or sensorycomplaints following an accident or fall. How the facility plans to monitor its performanceto make sure that solutions are sustained. Beginning 03/09/2026 the DON or designee willconduct weekly audits of all fall/incident SBARscompleted during the prior week to verify that:physician notification is documented within therequired timeframe. All reports or findings of non-compliance shall be presented by Admin anddiscussed in the Quality Assurance PerformanceImprovement meetings (QAPI). QAPI committeeshall review and monitor the effectiveness of theseplans monthly and then quarterly after 3 months. The effectiveness of the plan shall be measured bythe occurrences and non-occurrences of the sameissues or problems. QAPI Committee shall focusand discuss further actions by developingPerformance Improvement Plan (PIP) for areas orissues identified as recurring or trendingnegatively to implement a new and more effectiveplan of actions.
Failure to Reposition Resident With Multiple Stage 4 Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services to prevent the formation and promote the healing of pressure injuries by not ensuring a resident was repositioned every two hours as care planned. The resident was initially admitted and later readmitted with multiple stage 4 pressure ulcers, including to the sacral region, left hip, right buttock, and left buttock. The resident’s care plans, dated 11/7/2025 and 2/3/2026, documented impaired skin integrity with stage 4 pressure injuries to the sacrococcyx, left ischium, and left posterior hip, with interventions that included keeping affected areas clean and dry, monitoring for adverse changes, and turning and repositioning every two hours or as needed. The MDS dated 2/5/2026 indicated the resident had intact cognitive skills for daily decision making, bilateral lower extremity impairment, required supervision or touching assistance for rolling, and had stage 4 pressure ulcers. On observation, the resident was seen lying on his back in bed on multiple occasions. During an interview, the treatment nurse stated the resident needed help with repositioning while awake and that, although the resident previously used a timer on his phone while asleep, he now needed significantly more help due to wearing a leg brace. In a concurrent observation and interview, the resident reported that staff had not offered or assisted with repositioning. The CNA interviewed confirmed that the resident could not move his legs, required staff to carry his legs when repositioning from side to side, and was supposed to be repositioned every two hours to avoid pressure injuries and prevent current wounds from worsening. The CNA further stated that during his 7 AM to 3 PM shift he had only repositioned the resident once around 9 AM and that no other staff had repositioned the resident during that time. He acknowledged that the resident was not efficient with repositioning himself, needed assistance with managing the leg brace during turns, and that he did not follow the standard procedure of repositioning the resident every two hours during his eight-hour shift. The Director of Rehabilitation confirmed the resident was paraplegic, unable to use his lower extremities, wore a knee brace that limited movement, and required staff to hold the leg during repositioning. The DON stated the resident needed staff assistance with repositioning every two hours and that staff were required to offer repositioning even if residents declined. The facility’s policy on Prevention of Pressure Injuries, revised 7/12/2023, directed staff to reposition residents as indicated on the care plan, which was not followed in this case.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 02/25/2026 Resident 1 was offered to be repositioned but declined the assistance. The resident was educated on the importance of repositioning every two (2) hours to promote wound healing and prevent further skin breakdown and instructed to use the call light to request assistance when ready to be repositioned. CNA 1 was provided with reeducation on 02/27/2026 regarding policy and procedure titled "Prevention of Pressure Injuries", with specific emphasis on the requirement to turn and reposition residents per care plan and with emphasis on facility's responsibility to continue to offer and encourage repositioning every two (2) hours regardless of resident's preference. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. From 02/26/2026 thru 02/27/2026 The DON and QAN identified of all residents with elevated risk for pressure injury development and those with active pressure ulcers to ensure plan of care is being followed; no other residents were identified to have been affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. On 02/27/2026 DON and Director of Staff Development re-educated all licensed nursing staff (LVNs and RNs) and Certified Nursing Assistants (CNA) on the facility's policy and procedure titled "Prevention of Pressure Injuries", with specific emphasis on the requirement to turn and reposition residents per care plan. How the facility plans to monitor its performance to make sure that solutions are sustained. Beginning 03/09/2026 the DSD will conduct rounds of the facility and observe CNAs during ADL care to ensure residents plan of care is being followed. All reports or findings of non-compliance shall be presented by Admin and discussed in the Quality Assurance Performance Improvement meetings (QAPI). QAPI committee shall review and monitor the effectiveness of these plans monthly and then quarterly after 3 months. The effectiveness of the plan shall be measured by the occurrences and non-occurrences of the same issues or problems. QAPI Committee shall focus and discuss further actions by developing Performance Improvement Plan (PIP) for areas or issues identified as recurring or trending negatively to implement a new and more effective plan of actions.
Smoke Infiltration from Burnt HVAC Filter Due to Roofing Torch Work
Penalty
Summary
The facility failed to ensure a safe environment free of accident hazards when smoke from a burnt HVAC unit filter entered an interior hallway leading to the front lobby. On 1/10/2026, multiple staff, including the DON, LVNs, CNA, Activity Director, maintenance staff, and the receptionist, reported smelling something burning, detecting smoke or haze in the hallway, and noting a burnt or plastic-like odor. The DON stated he was notified at 10:59 AM by an RN that there was smoke inside the facility, and paramedics who were on-site for a resident’s change of condition also noticed smoke in the building. Staff reported that the smoke detector did not alarm during the event. The Maintenance Director reported that maintenance staff informed him of smoke and a burning smell, traced to a ceiling vent connected to HVAC unit 15. During observation with the Administrator, HVAC unit 15’s filter was found partially burnt, and the Administrator explained that roofing workers using a torch to patch the roof ignited the HVAC filter, causing smoke to travel down the vent into the facility. Staff interviews confirmed that residents’ doors were ordered closed in response to the smoke and that paramedics assisted by opening the front door and turning on fans in the hallway. The DON and LVNs acknowledged that smoke inhalation is harmful and can cause respiratory distress, particularly for residents with underlying respiratory conditions. Review of the facility’s Accidents/Incidents policy indicated the facility is required to provide a safe and secure environment for staff and residents, which was not maintained when smoke entered the occupied hallway and the smoke detection system did not alarm.
Failure to Ensure Timely Oncology Follow-Up for Resident with Cancer
Penalty
Summary
The facility failed to ensure that a resident with non-Hodgkin lymphoma received all necessary services, specifically a scheduled oncology appointment as prescribed upon discharge from an acute care hospital. The resident, who also had end stage renal disease, heart failure, and adult failure to thrive, was admitted with orders for outpatient treatment with rituximab and a follow-up appointment with an oncologist. Documentation showed that the resident did not attend the scheduled oncology appointment due to insurance issues, and there was no evidence in the medical record that the primary care physician was notified of the missed appointment or that the appointment was rescheduled. Interviews with the DON and the resident's primary care physician confirmed that facility staff did not follow protocol to notify the physician or reschedule the missed specialist appointment. The facility's policy required timely and coordinated referrals to medical specialists, including documentation and follow-up, but these steps were not taken. As a result, the resident did not receive an evaluation and treatment plan for their cancer as prescribed.
Failure to Protect Resident Privacy Due to Unrestricted Camera Use in Shared Room
Penalty
Summary
The facility failed to secure privacy for three residents by allowing a responsible party (RP) to remotely control a tablet with a camera in a shared resident room. The RP used the device to monitor his family member continuously, including during personal care activities such as bathing, toileting, and dressing. Staff interviews confirmed that the RP could see and hear not only his family member but also the other residents and staff in the room, including during private care activities. The RP also insisted on keeping curtains open to maximize the camera's view, further compromising the privacy of all residents in the room. Residents expressed discomfort and concern about being watched and having their privacy invaded. One resident with intact cognitive skills explicitly stated she did not consent to the surveillance and felt uncomfortable using the restroom due to the camera. Another resident reported sleep disturbances and distress due to the camera being on at all times and the associated light and noise. Staff also reported feeling uncomfortable and observed that the camera captured images and audio of all residents and staff in the room, raising concerns about HIPAA violations and the privacy of medical information. A review of facility policies revealed that there was no care plan addressing the use of the electronic device in the room, despite the facility's policy requiring protection of resident privacy and dignity. The policy also specified the use of headphones for video calls, which was not followed. The Director of Nursing acknowledged that the current situation did not respect the privacy and dignity of the residents and that the RP's actions were invasive to both residents and staff.
Failure to Assess, Notify Physician, and Develop Care Plan for Resident's Generalized Itching
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Parkinson's disease, chronic kidney disease, type II diabetes mellitus, and anxiety disorder, experienced ongoing generalized itching without receiving appropriate assessment, care, or timely physician notification. The resident, who had severely impaired cognitive function and required substantial assistance with daily activities, repeatedly complained of itching and was observed with scratch marks and red, flaky skin over several months. Despite these complaints and visible symptoms, there was no evidence that licensed staff performed a thorough skin evaluation or developed a care plan specific to the resident's itching. On multiple occasions, staff, including a Licensed Vocational Nurse (LVN), failed to notify the physician promptly about the resident's worsening condition. The LVN acknowledged not informing the physician immediately after the resident reported whole-body itching and did not provide any treatment or medication for the symptoms. Certified Nurse Assistants (CNAs) observed and reported the resident's persistent scratching and skin damage but only applied lotion without further escalation or intervention. Record reviews confirmed that no medication or treatment orders were in place for the resident's itching, and there was no care plan addressing the issue. The facility's policy required notification of the physician and care plan updates for significant changes in a resident's condition, but these steps were not taken. The Director of Nursing confirmed that the lack of physician notification and absence of a care plan for the resident's itching constituted a failure to provide necessary care and treatment as required by facility policy.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Maintain Call Devices Within Easy Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that call devices were maintained within easy reach for two residents with significant physical and cognitive impairments. For one resident with encephalopathy, cerebral palsy, and bilateral hand contractures, the call pad was observed hanging below the bed and out of reach, despite the resident's dependence on staff for all activities of daily living and the need for the call pad to be positioned near the chest area due to hand contractures. Both a CNA and an LVN confirmed that the call pad was not accessible and should have been placed within easy reach to allow the resident to request assistance. For another resident with epilepsy, dysphagia, and Alzheimer's disease, the call pad device was found on the floor near the head of the bed, making it inaccessible. This resident had severe cognitive impairment and required substantial to maximal assistance with daily care. An LVN confirmed that the call pad was not within easy reach and should have been accessible to ensure timely care. The facility's policy requires that call lights be within easy reach for residents in bed or confined to a chair, but this was not followed in these cases.
Failure to Follow IV Therapy Protocols and Documentation Requirements
Penalty
Summary
The facility failed to follow its own policies and procedures regarding intravenous (IV) therapy for two residents. For one resident with diagnoses including type 2 diabetes and osteomyelitis, the IV tubing used to administer Ceftriaxone was observed to be unlabeled during a room visit. The licensed vocational nurse confirmed the tubing was not labeled and acknowledged that labeling is required to track the age of the tubing and prevent bacterial contamination. The Director of Nursing also verified that the facility's policies require IV tubing to be labeled with the date and time for infection control purposes, and that failure to do so violates both the infection prevention and administration set/tubing change policies. For another resident with a history of ESBL-resistant Klebsiella infection and Alzheimer's disease, the care plan required IV site monitoring every shift while receiving Ertapenem. Review of the IV therapy medication record revealed that there were no registered nurse initials indicating that the IV site was checked during multiple night shifts. Interviews with nursing staff confirmed that the IV site was not checked or flushed as required, and the MDS nurse verified that documentation was incomplete, stating that if it was not documented, it was not done. The facility's policy specifies that the venous access site must be monitored and documented at least every shift. These deficiencies were identified through observation, interviews with staff, and review of medical records and facility policies. The failures included not labeling IV tubing and not consistently monitoring and documenting IV site assessments as required by the facility's infection control and IV therapy protocols.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Improper Disposal of Garbage and Refuse Due to Uncovered Dumpsters
Penalty
Summary
Two of four dumpsters in the facility's garbage area were observed with lids left exposed and not completely closed, as confirmed by the Maintenance Supervisor during an observation and interview. The Maintenance Supervisor acknowledged that the dumpsters were full and that the lids should have been closed according to facility policy, which is intended to prevent pests from accessing the trash. A review of the facility's Policy & Procedures on Sanitation and Infection Control: Waste Control and Disposal indicated that outside trash dumpster lids are required to be kept closed. No information about specific residents or their medical conditions was provided in relation to this deficiency.
Failure to Coordinate and Document Hospice Services for Two Residents
Penalty
Summary
The facility failed to ensure proper coordination of care between facility staff and hospice providers for two residents who were receiving hospice services. For one resident with a history of cerebral infarction and intracerebral hemorrhage, the facility did not maintain complete hospice nursing visitation calendars or documentation for June and July. The hospice binder lacked required sign-in sheets and care notes from registered nurses, licensed vocational nurses, and nurse aides, as stipulated by the hospice agreement. The only available documentation was a social worker's signature for one date, and the facility's designated staff confirmed that without proper documentation, it was unclear if visits occurred or what care was provided. For another resident with Alzheimer's disease and hemiplegia, the facility was unable to verify that scheduled hospice visits by registered nurses and licensed vocational nurses took place in June and July. The hospice visiting calendar and sign-in forms were incomplete, and there were no corresponding nursing notes. Facility staff, including licensed vocational nurses, reported not seeing hospice nurses visit the resident, and the medical records director could not locate any hospice notes or sign-in information for the scheduled visits. The director of nursing acknowledged that the facility should have ensured collaborative communication and documentation between facility and hospice staff, as required by policy and the hospice agreement. Facility policy required coordination of care, communication, and documentation between facility and hospice staff to ensure residents' needs were met. The policy also designated specific staff to coordinate hospice care and required that hospice staff sign in and provide visit notes. The lack of documentation and incomplete records for both residents indicated that the facility did not follow its own policies or the hospice agreement, resulting in a failure to ensure that hospice care and services were provided as ordered by the physician.
Failure to Properly Dispose of Medical Waste According to Facility Policy
Penalty
Summary
A deficiency occurred when standard infection prevention and control practices were not followed during the disposal of medical waste. During wound care for a resident with a sacral wound that was bleeding profusely, an LVN discarded soiled dressings and blood-saturated gauze into a clear plastic bag, which was then placed in a separate black bin rather than in a designated medical waste container. The LVN stated that the resident had previously been on contact isolation for a stage four pressure ulcer, but the isolation had been discontinued two days prior. The Infection Control Nurse (IPN) confirmed that no red bags were used for disposing of the medical waste, citing the discontinuation of contact isolation as the reason, and stated that the facility did not have color-coded bins or containers for hazardous or medical waste. A review of the facility's policy and procedure on medical waste handling indicated that items soiled with visible blood must be placed in red plastic bags or containers, and either saturated with a bleach solution or incinerated. Despite this policy, the IPN acknowledged that the facility lacked the required color-coded bins for proper disposal of medical waste. The failure to follow the facility's own policy and procedure for the safe and appropriate handling of medical waste was observed and confirmed through staff interviews and record review.
Deficiencies in Laundry Maintenance, Documentation, and Environmental Cleanliness
Penalty
Summary
The facility failed to maintain proper cleaning and documentation procedures in the laundry area and did not ensure cleanliness in resident restrooms and rooms. Specifically, lint was found in the lint trap of one dryer during observation, despite facility policy requiring lint removal after each use or every three hours. The lint removal log for the specified date was incomplete, with a blank entry for a scheduled time, and staff could not explain the omission. Additionally, the laundry water temperature log contained a future-dated entry, indicating that the required temperature checks were not performed at the scheduled times, as confirmed by staff and the maintenance supervisor. In another instance, yellow-brownish fluid, identified as urine, was observed on the toilet seat riser chair and the floor in a resident restroom and adjoining room. The infection prevention nurse and DON confirmed that the presence of urine on these surfaces was unsanitary and not in accordance with facility policy, which requires a clean and safe environment for residents. The facility's policies on laundry maintenance, water temperature, and maintaining a homelike environment were not followed as observed and confirmed through staff interviews and record reviews.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A deficiency was identified when a certified nurse assistant (CNA) was observed standing above a resident's eye level while assisting with mealtime, rather than sitting or positioning themselves at eye level with the resident. This occurred during breakfast in the resident's room, with a registered nurse (RN) present who did not intervene or instruct the CNA to adjust their position. The facility's policy requires staff to provide care in a manner that respects and enhances each resident's dignity, including maintaining eye-level interaction during assistance. The resident involved had diagnoses of dementia, Parkinson's disease, and quadriplegia, and required varying levels of assistance with activities of daily living, including eating. Interviews with staff confirmed that proper practice is to be at eye level with residents during feeding to show respect and maintain dignity. The failure to follow this practice was acknowledged by multiple staff members, and the facility's policy supports the expectation of maintaining resident dignity during care.
Failure to Provide Clean, Undamaged Bed Linen
Penalty
Summary
A deficiency was identified when a resident was found to have bed linen that was damaged with over thirty small holes near the bottom of the sheet. The resident, who had chronic obstructive pulmonary disease, type 2 diabetes mellitus with chronic kidney disease, and muscle weakness, required varying levels of assistance with daily activities but had no cognitive impairment and was able to make his own decisions. During an observation, the damaged bed sheet was noted, and the resident expressed discomfort and dissatisfaction with the condition of the linen. Interviews with staff confirmed that the damaged sheet was uncomfortable and could negatively affect residents' self-esteem, and that such conditions do not provide a homelike environment. The facility's policy requires that residents be provided with clean and good condition linens as part of a safe, clean, and comfortable environment. The failure to provide undamaged bed linen was observed and acknowledged by both direct care staff and facility management.
Failure to Document Rationale for Extended PRN Psychotropic Medication Use
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from unnecessary psychotropic drug use by not documenting a rationale for extending a PRN (as needed) Lorazepam order beyond 14 days, as required by facility policy. The resident, who had diagnoses including dementia, depression, and anxiety disorder, was prescribed Lorazepam PRN for anxiety manifested by repetitive verbal outbursts, with an order set for 30 days. The psychiatric follow-up note indicated continued use of Lorazepam to assist with behavior management, but did not provide a documented rationale for extending the PRN order beyond the 14-day policy limit. Interviews with facility staff, including a Licensed Vocational Nurse, Pharmacy Consultant, and the Director of Nursing, confirmed that the Lorazepam order was not limited to 14 days and lacked the required documentation for extension. The facility's policy specified that PRN psychotropic medication orders should be limited to 14 days unless a prescriber documents the rationale for extension and specifies the duration. In this case, there was no psychiatrist documentation justifying the extension prior to the 30-day order, resulting in non-compliance with the facility's policy and procedures.
Failure to Develop Individualized Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents with specific clinical needs. For one resident with end stage renal disease and dependence on dialysis, the physician ordered a daily fluid restriction of 1,000cc. Despite this order being documented in the resident's records, there was no care plan created to address the fluid restriction. Both the LVN and the DON confirmed that a care plan should have been in place to guide staff in managing the resident's fluid intake and to prevent complications related to fluid overload. Another resident, who was readmitted with diagnoses including cellulitis, long-term antibiotic use, and a deep incisional surgical infection, was receiving intravenous antibiotics as ordered by the physician. The medication administration record confirmed that the resident was receiving IV Vancomycin and Ceftriaxone for a surgical wound infection. However, there was no individualized care plan initiated to address the administration of IV antibiotics. The DON and the MDS nurse both acknowledged that a care plan should have been developed to ensure all staff were aware of the resident's needs, goals, and interventions related to IV therapy. A third resident, with a history of pressure ulcers, abnormal posture, and muscle weakness, was observed using a bolster low air loss mattress. While the resident had a care plan for the use of a low air loss mattress for skin and wound maintenance, there was no care plan specifically addressing the use of the bolster feature. Staff interviews and record reviews confirmed the absence of a care plan for the bolster mattress, which was used to prevent the resident from sliding or falling out of bed. The DON verified that a care plan should have included monitoring the placement of the bolster to ensure safety and prevent additional skin issues.
Failure to Obtain Physician Order for Bolster Low Air Loss Mattress
Penalty
Summary
A deficiency occurred when a resident with a history of a sacral pressure ulcer, abnormal posture, and muscle weakness was provided with a bolster low air loss mattress (LALM) without a corresponding physician's order. The resident was assessed as being at moderate risk for pressure sores, requiring substantial to maximal assistance with daily activities, and was observed using the bolster LALM in bed. Staff interviews confirmed that the mattress was in use to prevent the resident from sliding or falling out of bed, but review of the resident's active orders revealed that only a standard low air loss mattress was ordered, not the bolster version. Further interviews with nursing staff and the DON confirmed that the decision to use the bolster LALM was made by the interdisciplinary team for the resident's safety, but the specific order for this equipment was not documented in the physician's orders. Additionally, the facility was unable to provide a policy and procedure specific to the use of bolster low air loss mattresses, and the existing policy only addressed general air mattress use for pressure ulcer prevention and healing.
Failure to Administer Prescribed Water Flush for GTube Resident After Medication
Penalty
Summary
A deficiency occurred when a resident with a gastrostomy tube (GTube) did not receive the prescribed amount of water flush after medication administration. The resident, who was dependent on tube feeding for all nutrition and hydration and had severely impaired cognitive skills, was observed receiving only 5 cc of water flush after medications, despite physician orders and the care plan specifying 30-50 cc of water before and after medication administration. The resident's care plan also included interventions to ensure adequate hydration and nutrition through proper tube flushing. The Licensed Vocational Nurse (LVN) responsible for administering the medications acknowledged that the correct amount of water flush was not provided and stated awareness of the importance of following the physician's order to prevent tube clogging and ensure proper medication administration. The facility's policy on enteral nutrition also required that nutritional support be provided as ordered. The Director of Nursing confirmed that water flushes are to be given as ordered, but the observation and record review demonstrated that the prescribed protocol was not followed for this resident.
Failure to Monitor and Document Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to monitor and document the daily fluid intake for a resident with end stage renal disease (ESRD) and heart failure who was on dialysis and had a physician-ordered fluid restriction of 1000cc per day. The resident's care plan specified the distribution of fluids across nursing shifts and meals, and the order included instructions that no water pitcher be kept at the bedside. However, review of the Medication Administration Record (MAR) and interviews with nursing staff revealed that there was no documentation of the resident's actual fluid intake for any shift over a two-week period. The MAR only allowed staff to acknowledge the fluid restriction order, not to record intake amounts, and there was no alternative location for this documentation. Multiple licensed nursing staff confirmed that fluid intake amounts were not recorded as required, and the resident's chart lacked any notes indicating intake for the period in question. Staff acknowledged that without accurate and complete intake records, it was not possible to ensure the resident's fluid intake remained within the prescribed limits. The Director of Nursing also confirmed that monitoring and documentation of fluid intake should have occurred according to policy and physician orders. Review of facility policy indicated that special care monitoring, including fluid restriction, is required for residents on dialysis.
Failure to Accurately Document Controlled Medication Counts at Shift Change
Penalty
Summary
The facility failed to provide a consistent and accurate account of controlled medications by not ensuring staff completed documentation of narcotic counts at each shift change. Record reviews revealed multiple blank entries on Narcotic Release Forms for several medication carts across various dates, indicating that staff did not always document the required shift-to-shift narcotic counts. Interviews with licensed nurses and the Director of Nursing confirmed that the forms were incomplete and should have been filled out according to facility policy, which requires two licensed nurses to conduct and document a physical inventory of all controlled medications at each shift change. One resident involved had significant medical needs, including a feeding tube, severe cognitive impairment, and dependence on staff for daily activities. The incomplete documentation of controlled medication counts meant there was no way to ensure that narcotics were properly accounted for or administered safely and accurately to residents. The Director of Nursing acknowledged that the lack of complete and accurate forms could result in discrepancies in the amount of narcotics available for residents and potentially delay treatments.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Water Flushes
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with three medication errors identified out of 25 observed medication administration opportunities, resulting in a 12.5% error rate. Specifically, a Licensed Vocational Nurse (LVN) did not administer the prescribed amount of water flush (10-15 cc) between each medication given via gastrostomy tube (GTube) to a resident, instead using only 5 cc of water between medications. This was observed during medication administration at the resident's bedside, and the LVN acknowledged the error, stating that the correct amount of water should have been used as per the physician's order. The resident involved had significant medical needs, including gastrostomy status, moderate protein-calorie malnutrition, aphasia, and severely impaired cognitive skills, and was dependent on tube feeding for nutrition and hydration. The resident's care plan and medication administration record both specified the need for 10-15 cc water flushes between medications. The facility's policy also required medications to be administered as prescribed. The Director of Nursing confirmed that water flushes should be given as ordered to ensure proper medication administration.
Expired Glucose Test Strips Used During Blood Sugar Testing
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) used expired glucose test strips to check a resident's blood sugar during medication administration. The LVN was observed at the resident's bedside using test strips from a bottle that was past its expiration date. Upon interview, the LVN acknowledged that the strips were expired, should not have been used, and should have been discarded from the medication cart. The facility's Director of Nursing (DON) confirmed that facility protocol requires all glucose test strips in use to be current and discarded once expired, as expired strips can provide inaccurate results. The resident involved had a history of type 2 diabetes mellitus, peripheral vascular disease, and a gastrostomy, and was dependent on staff for all activities of daily living. The resident's medication administration record indicated the use of insulin based on blood glucose readings. The facility's policy and procedure required checking expiration dates prior to administering medications and ensuring safe administration practices. Despite these protocols, expired test strips were used for blood sugar testing, constituting a failure to ensure drugs and biologicals were properly labeled and stored, and that expired supplies were not used in resident care.
Failure to Maintain Accurate and Complete Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, resulting in deficiencies in documentation and communication among healthcare providers. For one resident with a history of ESBL resistance, Klebsiella infection, and Alzheimer's disease, the IV therapy medication record was not initialed by the night shift nurse for multiple consecutive days, indicating that required IV site checks were not documented. Additionally, the record contained inaccurate information, as a nurse documented an IV flush and site check after the resident's IV access had already been removed. The IV therapy medication record was also missing essential information such as the physician's name, allergies, and diagnoses, contrary to facility policy. Interviews with nursing staff confirmed that documentation was incomplete and, in some cases, inaccurate, with one nurse unable to explain why her initials appeared for a procedure that was not performed. Another resident, who was dependent on a gastrostomy tube for nutrition and medication administration due to severe cognitive impairment and aphasia, did not receive water flushes as ordered between and after medication administration. Observation revealed that only 5 cc of water was used for flushes, rather than the ordered 10-15 cc between medications and 30-50 cc after. The Medication Administration Record (MAR) inaccurately reflected that the correct flushes were given and was signed by a nurse who did not perform the procedure. Both the nurse who administered the flushes and the nurse whose initials appeared on the MAR confirmed the documentation was inaccurate. Facility policies require that all medical record documentation be objective, complete, and accurate, including the administration of medications, treatments, and any changes in resident condition. The Director of Nursing confirmed that only the nurse administering care should document it in the MAR, and that accurate documentation is essential for ensuring appropriate care. The failures in documentation for both residents were confirmed through interviews, record reviews, and direct observation.
Failure to Post Up-to-Date Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that accurate and up-to-date nurse staffing information was posted daily in a visible and prominent location, as required. Observations on multiple occasions revealed that the staffing information displayed at the front reception desk was outdated, showing data from several days prior rather than the current day. No updated staffing postings were found for the dates in question, and the required information was not readily accessible to residents and visitors. Interviews with facility staff indicated a lack of clarity and communication regarding responsibility for posting staffing information, particularly over the weekend. The Director of Staff Development (DSD) stated he was responsible for weekday postings, while the weekend Registered Nurse Supervisor (RNS) was supposed to handle weekend postings. However, the RNS reported she was unaware of this assignment and did not typically manage staffing postings. The facility's policy requires daily posting of direct care staffing numbers for every shift, but this procedure was not followed during the period reviewed.
Resident Exposed During Post-Shower Transfer, Violating Dignity and Privacy
Penalty
Summary
The facility failed to maintain a resident's dignity and privacy during post-shower care. Observation revealed that a certified nursing assistant (CNA) took a resident out of the shower room with only a gown covering the front of the resident's body, leaving both sides and the back exposed. The CNA acknowledged that the resident should have been fully covered during the transfer from the shower room to the resident's room. The Director of Nursing (DON) confirmed that the resident should have been covered with a poncho that would shield the entire body and shower chair for dignity. The resident, who was cognitively independent but required substantial assistance with bathing and dressing due to muscle weakness and diabetes mellitus, reported feeling disrespected and stated that a blanket should have been used for coverage. A review of the facility's policy on resident dignity and personal privacy indicated that residents should be shielded during all personal care and treatment procedures, and should be appropriately draped and dressed to avoid exposure and embarrassment. The policy specifically required covering residents during transfers to the shower or toilet. The failure to follow these procedures resulted in the resident being exposed during transfer, in violation of the resident's right to privacy and dignity.
Failure to Timely Report and Respond to Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its Abuse Investigation and Reporting policy for one resident who alleged physical abuse by another resident. Specifically, after a resident reported to an RN that another resident had jumped on and hit his head, the incident was not reported to the State Agency, ombudsman, or local law enforcement within the required two-hour timeframe. The Director of Nursing confirmed that the allegation should have been reported and investigated promptly, but this did not occur, and the DON was not made aware of the incident until several hours later. Additionally, the facility did not immediately separate the two residents involved in the alleged abuse, as required by policy to prevent further harm. Both residents remained in the same room for nearly six hours after the incident was reported, despite one resident expressing discomfort about sharing a room with the alleged abuser. The facility's own policies indicated that residents should be protected from abuse and separated during investigations, but these procedures were not followed in this case.
Failure to Administer Ordered Tube Feeding to Resident
Penalty
Summary
Nursing staff failed to ensure that a resident with a gastrostomy feeding tube (GT) received the prescribed volume of tube feeding as ordered by the physician. The resident, who had diagnoses including protein calorie malnutrition, a stage 3 pressure ulcer on the left heel, and stroke with dysphagia, was dependent on tube feeding for all nutrition and hydration. The physician's order specified enteral feeding at 60 cc/hour for 20 hours daily, to be administered from 12 PM to 8 AM, providing a total of 1200 cc in 24 hours. However, during observation and interview, it was confirmed by an LVN that the tube feeding was off when it should have been running, and the LVN admitted to forgetting to restart the feeding at the scheduled time. The resident's care plan and facility policies required adherence to physician orders for tube feeding to support nutritional needs and wound healing, especially for residents at risk for or with pressure ulcers. The facility's policies also outlined procedures for preventing errors in enteral feeding administration, including verifying orders and ensuring proper connections. Despite these protocols, the failure to administer the tube feeding as ordered resulted in the resident not receiving the required nutrition during the prescribed period.
Failure to Maintain Resident Dignity Due to Loud Television Volume
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity by not maintaining the television volume at a comfortable level in a shared room. The incident involved a resident with chronic obstructive pulmonary disease, type 2 diabetes with chronic kidney disease, and acute respiratory failure, who was assessed as having moderately impaired cognitive skills and required varying levels of assistance with daily activities. On the night of the incident, the resident was unable to sleep due to the loud volume of the television operated by the roommate. This led to a verbal confrontation between the two residents, with the affected resident attempting to lower the volume and turning off the television at the roommate's bedside. Staff interviews revealed that facility personnel were expected to check on residents' comfort and address such issues during routine night rounds, especially during quiet hours. Both a licensed vocational nurse and a registered nurse confirmed that the television volume should have been kept at a low and comfortable setting during quiet time, and that staff should have intervened to address the noise complaint. Facility policies reviewed indicated that care should be provided in a manner that maintains resident dignity and comfort, including maintaining television settings at a level agreeable to all residents in the room. The failure to address the television volume resulted in a violation of the resident's right to a dignified and comfortable environment.
Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 16 and 286, were informed and provided with written information regarding their right to formulate an advance directive. This deficiency was identified through interviews and record reviews, which revealed that neither resident had an advance directive or an advance healthcare directive acknowledgment form in their medical records. Resident 16, who had intact cognitive skills for daily decision-making, was admitted and readmitted to the facility without the necessary documentation in their chart. The Admission Coordinator confirmed the absence of the advance directive acknowledgment form, which should have been included in the admission packet and followed up by the social worker. Similarly, Resident 286, who had severely impaired cognitive skills, also lacked the necessary documentation in their medical record. The Social Services Director acknowledged the absence of the advance directive acknowledgment form, which was supposed to be provided upon admission and included in the admission packet. The Director of Nursing confirmed that the advance directive should be kept in the chart, and if not available, an acknowledgment form should be present. The facility's policy and procedure on advance directives, revised in August 2023, required that residents be provided with written information about their rights to refuse or accept medical treatment and to formulate an advance directive upon admission.
Failure to Provide Grooming Care Assistance
Penalty
Summary
The facility failed to provide grooming care assistance as per its policy for two residents, leading to a deficiency in care. Resident 43, who was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and dementia, required assistance with activities of daily living (ADLs) due to severely impaired cognitive skills. Observations revealed that Resident 43 had long and yellowish fingernails, indicating a lack of grooming care. Certified Nursing Assistant (CNA) 9 confirmed that Resident 43 was unable to clip his own nails and required assistance, which was not provided. Furthermore, there was no documentation of any refusal of care by Resident 43, as required by the facility's procedures. Similarly, Resident 75, who had diagnoses of contracture, dementia, and Parkinson's Disease, was dependent on staff for personal hygiene due to severe cognitive impairment and physical limitations. Observations showed that Resident 75 had long fingernails, which were not trimmed by the facility staff. The resident's responsible party expressed concern about the lack of nail care, and CNA 9 acknowledged the resident's dependency on staff for grooming. Despite the facility's policy requiring CNAs to document refusals of care, there was no record of any such documentation for Resident 75. Interviews with the Director of Staff Development and the Director of Nursing revealed that the facility's policy required CNAs to check and clip residents' nails as needed to prevent self-inflicted injuries. However, there was no evidence of compliance with this policy for Residents 43 and 75. The facility's failure to adhere to its own policies and procedures for grooming care assistance resulted in a deficiency that could potentially impact the residents' quality of life.
Failure to Implement Seizure Precautions
Penalty
Summary
The facility failed to implement necessary interventions to prevent accidents for three residents with a history of seizures. Resident 58, who was diagnosed with epilepsy, quadriplegia, and dementia, had a physician's order to have both side rails padded for seizure precautions. However, observations revealed that only the right side rail was padded, leaving the left side rail unprotected. Interviews with staff confirmed that both side rails should have been padded according to the physician's order and facility policy. Similarly, Resident 103, who also had a diagnosis of epilepsy, was observed with only the right side rail padded, while the left side rail was missing the pad. The Licensed Vocational Nurse stated that the pad was being cleaned, but acknowledged that both side rails should be padded to protect the resident during a seizure. The facility's seizure precaution policy required side rails to be padded for residents with a history of seizures to prevent injury. Resident 28, diagnosed with epilepsy and severe cognitive impairment, was observed with unpadded side rails despite a care plan and physician's order indicating the need for padded side rails for seizure precautions. Staff interviews confirmed that padded side rails were standard practice for residents with seizures to prevent injury. The facility's policy emphasized the importance of implementing care plans and following physician orders to ensure resident safety.
Deficient Care in Catheter and Stoma Management
Penalty
Summary
The facility failed to provide necessary care and services for two residents, leading to potential health risks. For Resident 106, the facility did not monitor the Foley catheter as per the physician's order. The resident, who was admitted with generalized weakness and neuromuscular dysfunction of the bladder, had a care plan that required monitoring the catheter for drainage, redness, bleeding, irritation, crusting, or pain every shift. However, documentation was missing for several shifts, indicating that the monitoring was not performed. This lack of monitoring could lead to a urinary tract infection, as confirmed by the Director of Nursing. Resident 103, who was admitted with epilepsy, had a suprapubic stoma site that required daily dressing changes as per the physician's order. However, the dressing was not changed daily, and the resident reported that it had not been changed for four days, leading to an itchy and soiled dressing. The Treatment Administration Record indicated that the dressing was last changed on a different date than recorded, and there was no care plan related to the daily dressing change. This oversight increased the risk of infection at the stoma site, as noted by the Infection Prevention Nurse. The facility's policies and procedures for Foley catheter care and documentation emphasize the importance of preventing infections and maintaining accurate records. However, the lack of documentation and adherence to care plans for both residents highlights deficiencies in the facility's care practices. The absence of proper monitoring and documentation for Resident 106's Foley catheter and Resident 103's suprapubic stoma dressing change demonstrates a failure to follow established protocols, potentially compromising the residents' health and well-being.
Deficiencies in Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding oxygen administration for two residents, resulting in deficiencies in care. For Resident 7, the facility did not ensure that the oxygen was administered at the correct ordered setting as per the physician's order. The resident, who was admitted with diagnoses including metabolic encephalopathy and chronic obstructive pulmonary disease (COPD), was observed to have their oxygen set at 5 liters per minute (LPM), which exceeded the ordered range of 2 to 3 LPM, with a possible titration to 4 LPM. This discrepancy was confirmed by both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that the physician's order was not being followed. For Resident 129, the facility failed to change the oxygen nasal cannula (NC) every seven days as required, and did not maintain a clean oxygen concentrator. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was observed with NC tubing and a humidifier that were not labeled or dated, and an oxygen concentrator with visible stains. The Infection Prevention Nurse (IPN) and a Registered Nurse (RN) confirmed that the NC tubing and humidifier should be changed and dated every seven days to prevent bacterial growth and potential infection. The facility's policy did not include specific instructions for changing and dating the humidifier and tubing, which contributed to the oversight. The facility's failure to follow its own policies and procedures for oxygen administration and equipment maintenance posed a risk of complications for both residents. The observations and interviews with staff highlighted lapses in adhering to physician orders and infection control practices, which are critical for ensuring the safety and well-being of residents receiving oxygen therapy.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as per their policy and procedure, leading to potential health risks for residents. During an observation in the kitchen, it was noted that a container of chicken soup base and wheat flour was not sealed properly. The Dietary Supervisor confirmed this observation, and a Dietary Staff member acknowledged that all containers should be sealed to prevent cross-contamination and insect infestation, which could lead to resident illness. Additionally, the refrigerator designated for residents' food items brought from outside was found to be unclean. The Infection Preventionist observed brownish to blackish crusted food residue on the refrigerator door and spilled milk at the bottom. The Director of Nursing confirmed that all kitchen containers should be sealed and the refrigerator should be kept clean to prevent food contamination. The facility's policies from 2019 emphasized the importance of maintaining clean and properly sealed food storage to ensure food safety.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, leading to potential safety risks. Resident 124, who has Parkinson's disease and a history of falls, reported that the toilet seat in her bathroom was too low, causing discomfort and difficulty in using it safely. Despite being aware of the issue, the maintenance staff did not adjust the toilet seat height due to opposition from other residents. Observations confirmed that Resident 124 struggled to use the toilet, and staff interviews acknowledged the risk of falls due to the low seat height. Resident 186, who has hemiplegia and hemiparesis following a stroke, was found without access to his call light, which was not within reach. This resident, who is dependent on assistance for daily activities, was observed calling for help without success because the call light was placed on the opposite side of the bed or on a dresser, making it inaccessible. Staff interviews confirmed that the call light should have been placed on the resident's left side, where he could reach it, given his right-sided weakness. The facility's policies on accommodating resident needs and ensuring call lights are within reach were not followed, leading to these deficiencies. The failure to adjust the toilet seat height for Resident 124 and to ensure the call light was accessible for Resident 186 were direct violations of the facility's procedures, potentially compromising the safety and well-being of the residents involved.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for Resident 58, as observed during a survey. Resident 58, who was admitted with diagnoses including sepsis, gastrostomy status, and quadriplegia, was found to have fecal matter on the floor next to their bed. This observation was made during a concurrent interview with a Certified Nursing Assistant (CNA), who noted that the fecal matter appeared flattened, suggesting it had been run over by a wheel, such as a shower chair or wheelchair. The resident's care plan indicated they were dependent on staff for toileting hygiene and other daily activities due to severe cognitive impairment and mobility issues. Interviews with the Infection Prevention Nurse (IPN) and the Director of Nursing (DON) highlighted the facility's expectations for maintaining a clean environment. The IPN stated that fecal matter should be disposed of properly to prevent infection spread, and the DON emphasized the need for immediate cleaning of any fecal matter in the resident's room to maintain a safe and homelike environment. The facility's policies on infection control and maintaining a homelike environment were reviewed, indicating an established program to prevent disease transmission and ensure cleanliness, which was not adhered to in this instance.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to implement a care plan for Resident 28, who has a diagnosis of epilepsy, by not using padded side rails as ordered by the physician. Despite the care plan indicating the need for padded side rails to prevent injury during seizures, observations on multiple occasions revealed that the side rails were not padded. Interviews with staff, including a licensed vocational nurse and the infection preventionist, confirmed that the facility's standard practice for residents with seizures was to use padded side rails, and the failure to do so was against the physician's orders and the care plan. For Resident 103, the facility did not develop a care plan to address the treatment of the resident's suprapubic stoma site. The physician's order required daily cleaning and dressing of the stoma site, but observations and interviews revealed that the dressing was not changed for several days, and the site was not cleaned as required. The resident was observed scratching the area, and the dressing was noted to be soiled and dirty. The wound care Treatment Administration Record indicated discrepancies in the documentation of dressing changes, and staff confirmed the absence of a care plan related to the stoma site care. The facility's policy and procedures require a comprehensive, person-centered care plan with measurable objectives and timetables to meet residents' needs. However, the lack of implementation and development of care plans for Residents 28 and 103 demonstrates a failure to adhere to these policies, potentially placing the residents at risk for injury and infection.
Failure to Provide Communication Board for Resident with Aphasia
Penalty
Summary
The facility failed to provide a communication board in the language understood by a resident diagnosed with aphasia, hemiplegia, and hemiparesis. This resident, who was dependent on assistance for various activities of daily living, was admitted and readmitted with these conditions. The resident's care plan, initiated and revised over time, indicated the need for a communication board and translation services to help the resident communicate basic needs. However, during an observation, it was noted that the communication board was not present in the resident's room. Interviews with facility staff, including a Certified Nursing Assistant and the MDS Nurse, confirmed that the resident required a communication board and that it should have been available in the room. The facility's policy on resident rights emphasized the need for communication in a language the resident understands, yet this was not adhered to in the case of the resident. This oversight had the potential to delay appropriate care and treatment due to communication barriers.
Incorrect LAL Mattress Settings for Two Residents
Penalty
Summary
The facility failed to implement appropriate treatment for the prevention of pressure ulcers by not ensuring that the low air loss mattress (LAL) was set correctly for two residents. Resident 287, who was admitted with cerebral palsy and existing pressure ulcers, had a physician's order to monitor the LAL settings every shift. However, observations revealed that the LAL was set at 120 lbs, while the resident's weight was 91 lbs. This incorrect setting was confirmed by both the resident, who expressed discomfort, and a Licensed Vocational Nurse (LVN), who acknowledged the error and its potential impact on wound healing. Similarly, Resident 46, who was at high risk for developing pressure ulcers due to severe cognitive impairment and other health conditions, also had an LAL mattress prescribed for skin breakdown prevention. The resident's weight was recorded as 105 lbs, but the LAL was observed to be set at 120 lbs. An LVN confirmed the incorrect setting, noting that the LAL should be adjusted based on the resident's weight to prevent skin breakdown. The facility's policy and procedure, as well as the manufacturer's manual, indicated that the LAL settings should be adjusted according to the resident's weight to promote healing and prevent pressure ulcers. The failure to adhere to these guidelines for both residents resulted in a deficiency, as the incorrect LAL settings could hinder wound healing and increase the risk of developing new pressure ulcers.
Failure to Provide RNA Services as Ordered
Penalty
Summary
The facility failed to provide Restorative Nursing Assistant (RNA) services to Resident 106 as indicated in the physician's order. Resident 106 was admitted with diagnoses of generalized weakness and neuromuscular dysfunction of the bladder. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and dependency on assistance for various activities. A physician's order dated 7/3/24 required RNA services for passive range of motion (PROM) for the lower extremities and active-assisted range of motion (AAROM) for the upper extremities, to be performed five days a week. Upon review, it was found that there was no documentation or log of RNA services being provided to Resident 106, despite the order for services to start on 7/4/24. Interviews with RNA 1 and the Director of Rehab (DOR) confirmed the absence of documentation, indicating that the services were not performed. The Director of Nursing (DON) emphasized the importance of immediate documentation to ensure accuracy and prevent oversight. Resident 106 reported that the last assistance received was on 7/3/24, the day of discharge from physical therapy, and expressed concern about losing physical function. The facility's policy on Restorative Nursing Services, dated July 2017, mandates that residents receive restorative care to promote safety and independence. The lack of RNA services documentation suggests a failure to adhere to this policy, potentially putting Resident 106 at risk for a decline in physical function and the development of contractures. Interviews with the DOR and a Registered Occupational Therapist (OTR) highlighted the importance of RNA services in maintaining joint function and preventing decline.
Failure to Ensure Adequate Hydration for Resident
Penalty
Summary
The facility failed to ensure that Resident 112 received the required two liters of water daily as per the physician's order. This deficiency was identified through observations, interviews, and record reviews. Resident 112, who was admitted with a diagnosis of hyperosmolality and hypernatremia, had a physician's order to drink at least two liters of water daily and to be encouraged to drink electrolytes. However, the care plan for abnormal laboratory values related to chronic kidney disease did not include this intervention, and the facility's documentation did not accurately record the resident's fluid intake. Interviews with Resident 112 and their responsible party revealed that the resident was often thirsty and not regularly offered water or fluids by the staff. Observations showed that while a pitcher of water was present, there were no cups available for the resident to use, and the resident required assistance to drink. Staff members, including CNAs and LVNs, were unaware of the specific fluid intake requirements for Resident 112, and the facility's CNA Daily Charting Form only documented whether fluids were offered, not the actual intake. The facility's policy on hydration emphasized the importance of ensuring adequate fluid intake for residents, particularly those at high risk for dehydration. However, the policy was not followed, as evidenced by the lack of intake and output monitoring for Resident 112. Interviews with staff, including the MDS nurse and the Director of Nursing, highlighted the potential risks of not adhering to the physician's order, such as abnormal blood work and kidney issues, but these concerns were not addressed in the care plan or daily practices.
Failure to Follow Physician's Order for Medication Administration
Penalty
Summary
The facility failed to adhere to a physician's order for a resident, identified as Resident 124, by not checking the resident's heart rate before administering metoprolol, a medication used to treat high blood pressure and heart conditions. This oversight was observed during a medication administration session where the Licensed Vocational Nurse (LVN 2) did not measure the resident's heart rate prior to giving the medication, despite the physician's order specifying that the medication should be withheld if the pulse rate was less than 60. The LVN acknowledged the mistake, stating that the heart rate should have been checked to prevent potential adverse effects such as a further decrease in heart rate. Resident 124, who has Parkinson's disease and requires varying levels of assistance with daily activities, was admitted and readmitted to the facility with specific physician orders regarding medication administration. The facility's policy mandates that medications be administered as prescribed, which includes following all physician instructions. Interviews with the MDS nurse and the Director of Nursing confirmed that the physician's instructions were not followed, which could have led to adverse consequences for the resident.
Failure to Document RNA Services for a Resident
Penalty
Summary
The facility failed to ensure timely and accurate documentation of Restorative Nursing Assistant (RNA) services for one of the residents, identified as Resident 106. The resident was admitted with diagnoses of generalized weakness and neuromuscular dysfunction of the bladder. The resident's care plan included RNA services for passive and active-assisted range of motion exercises to prevent contractures and maintain or improve range of motion. However, there was no documentation or log of RNA services being provided to the resident from the start date of the order. During a review of the RNA services binders and the resident's order summary report, it was found that there was no RNA services log for Resident 106, despite an order for RNA services to begin on a specific date. RNA 2 admitted to signing the RNA services log form for the resident after the fact, covering dates from the start of the order to a later date, and acknowledged forgetting to obtain and document the log for the resident. This lack of documentation was confirmed by the Director of Rehab, who stated that if the RNA services log form is not filled out or initialed, it indicates that the services did not occur. The Director of Nursing emphasized the importance of documenting tasks immediately after completion to ensure accuracy and prevent memory lapses. The facility's policy and procedure on charting and documentation require that documentation be objective, complete, and accurate. The failure to document RNA services as per the facility's policy resulted in a deficiency in maintaining accurate medical records for Resident 106.
Deficiency in Hospice Care Coordination
Penalty
Summary
The facility failed to ensure that a resident, who was admitted to hospice care, received a comprehensive assessment for the plan of care, including the frequency of hospice staff visits. The resident, who had a history of malignant neoplasm of the colon, cerebrovascular disease, and hemiplegia following a cerebral infarction, was admitted to hospice care with a diagnosis of cerebrovascular disease. Despite being placed on hospice care, there were no physician orders or hospice calendar entries indicating the frequency of visits from hospice staff, such as registered nurses, health aides, spiritual counselors, and medical social workers. Interviews and record reviews revealed that the resident received hospice visits on only two occasions, with no visits documented from 7/13/24 to 7/19/24. The Director of Nursing confirmed that the hospice calendar was incomplete, lacking entries for hospice staff visits, and there was no documentation in the coordination notes or sign-in sheets. The facility's policy indicated that hospice services should be provided upon the order of attending physicians, and the agreement with the hospice required collaboration and documentation of care. The absence of a hospice calendar and documentation resulted in the resident not receiving the expected hospice care.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement standard infection prevention control practices for two residents. In the first instance, a Licensed Vocational Nurse (LVN 8) did not disinfect a shared blood pressure cuff after using it on Resident 10, who had a history of urinary tract infection. This oversight was observed when LVN 8 attempted to use the same cuff on another resident without cleaning it, which was acknowledged by the nurse as a mistake. The Director of Nursing (DON) and the Infection Prevention Nurse (IPN) confirmed that the blood pressure cuff should be disinfected before and after each use to prevent the spread of infections. In the second instance, LVN 1 failed to wear personal protective equipment (PPE) while administering medication to Resident 57, who had a gastrostomy tube and was on Enhanced Barrier Precautions (EBP) due to their susceptibility to infections. During the observation, LVN 1 admitted forgetting to wear the gown, which is part of the EBP protocol. Additionally, LVN 6 was observed mishandling the gastrostomy tube connection by placing a non-sterile cone connector on the GT machine, which could lead to contamination. LVN 6 acknowledged the error and the potential risk of infection. The facility's policies and procedures, including those for cleaning and disinfection of resident-care items and equipment, and for maintaining aseptic techniques during enteral feedings, were not followed. The DON emphasized the importance of adhering to EBP for residents with enteral feeding or open wounds to prevent infection transmission. The failure to follow these protocols posed a risk of infection to the residents involved.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
