Stoney Point Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chatsworth, California.
- Location
- 21820 Craggy View St., Chatsworth, California 91311
- CMS Provider Number
- 555574
- Inspections on file
- 59
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Stoney Point Healthcare Center during CMS and state inspections, most recent first.
A resident with encephalopathy, depression, and dementia, who required moderate to maximal assistance with ADLs, expressed discomfort with their room, and the responsible party requested a room change through Social Services. Social Services confirmed that another room was available and notified the RN Supervisor, but the transfer was not completed because the RN Supervisor reported being too busy during shift change. The DON confirmed that a room was available and that such requests should be acted on promptly, and facility policies state that residents are to be treated with dignity and that room changes are to be made when requested by the resident. This resulted in a failure to timely honor the resident’s request for a room change.
A resident's right to privacy and confidentiality was violated when the Social Services Director gave that resident's medical records to another resident's responsible party who had requested records. The SSD printed records from the printer and handed them over without confirming they matched the correct resident and without following the facility's required Authorization for Release of Records process, which involves review and approval by the MRD, DON, and Administrator. Facility policies on release of records and resident rights specified that records may only be released with proper authorization and that residents are entitled to confidentiality of their personal and medical information.
A resident with respiratory failure and severe cognitive impairment experienced a significant drop in oxygen saturation while receiving oxygen via nasal cannula. Facility staff did not increase the oxygen flow rate or switch to a non-rebreather mask as required by physician orders and facility policy. Paramedics arriving on scene found the resident still on low-flow oxygen and had to initiate high-concentration oxygen therapy before transferring the resident to the hospital.
Three residents received psychotropic medications without proper justification or monitoring. One resident was given an antipsychotic without documentation of required symptoms or evidence that non-drug interventions were attempted. Another was administered an anti-anxiety medication without first trying non-pharmacological approaches as ordered. A third resident received an anti-anxiety medication for weeks without behavioral monitoring to justify its use. These actions did not comply with facility policy or physician orders.
A resident did not receive the necessary care to maintain or improve range of motion or mobility, and there was no documented medical reason for the decline.
The facility did not act on consultant pharmacist recommendations for three residents, including failing to complete an EKG for a resident on Quetiapine, not ensuring proper documentation and monitoring for a resident on Seroquel, and lacking physician documentation for continued Klonopin use. These actions were not in accordance with facility policies and placed residents at risk for adverse effects.
Leftover food brought in by families and visitors was found in a resident refrigerator without proper labeling or resident identification. The Administrator in Training confirmed that all such food should be labeled with an identifier and use-by date, as required by facility policy, but this was not done in the observed instance.
Therapy staff did not accurately document the timing and completion of Rehab Joint Mobility Screens for several residents, failing to indicate late entries or how assessments were performed after the scheduled date. Additionally, a resident's diagnosis of anxiety was omitted from the medical record despite ongoing treatment, resulting in incomplete and inaccurate clinical documentation.
Staff did not knock or ask permission before entering the rooms of two residents with severe cognitive impairment and total dependence for ADLs. The CNA acknowledged forgetting to knock, and the DON confirmed that facility policy requires staff to do so to respect resident privacy and dignity.
A resident with impaired cognition and a need for supervision was found in bed with the call light on the floor and out of reach. Staff confirmed the call light should have been accessible, and facility policy requires it to be within easy reach for residents in bed or in a chair.
Two residents with significant medical needs had executed Advance Directives (ADs) that were not present in their active medical charts, despite facility policy requiring ADs to be accessible for staff reference. Both the Medical Records Director and Social Service Director confirmed the absence of these documents, and the ADON acknowledged that this failure meant staff could not easily access or honor the residents' healthcare wishes.
A resident with multiple diagnoses, including dementia and obstructive uropathy, was admitted with an indwelling catheter, but the baseline care plan developed within 48 hours did not document the catheter or related care needs. Facility staff confirmed the omission, which was inconsistent with policy requiring all immediate care needs to be addressed in the baseline care plan.
Two residents prescribed psychotropic medications did not have person-centered care plans developed or implemented to address their medication use. One resident with dementia and anxiety was given olanzapine without a corresponding care plan, and another resident with major depressive disorder and ADHD was prescribed amphetamine-dextroamphetamine without a care plan. Facility staff and policies confirmed that care plans were required for these medications to ensure proper monitoring and management.
A resident with cognitive impairment and multiple diagnoses lost her upper dentures, and although a dental evaluation was performed and further treatment was declined by the resident, the dental care plan was not updated or revised to reflect these changes, contrary to facility policy requiring care plan review after significant changes.
The facility did not accurately complete or update fall risk assessments for two residents with cognitive and mobility impairments after they experienced falls. In one case, a resident's fall was not documented in the fall risk assessment, and in another, staff failed to conduct a required fall risk assessment after a witnessed fall. These actions were not in accordance with facility policy, which requires timely and accurate fall risk assessments following such incidents.
A resident with end stage renal disease who was dependent on hemodialysis did not have their post-dialysis weight recorded by the dialysis center, and facility nursing staff did not follow up to obtain this information, resulting in incomplete documentation of dialysis care.
A resident was prescribed amphetamine-dextroamphetamine without a documented ADHD diagnosis, and staff failed to develop a care plan or obtain orders to monitor for adverse effects or effectiveness of the medication. Nursing and administrative staff confirmed that required monitoring and care planning for psychotropic medications were not completed, contrary to facility policy.
A resident with a documented egg allergy did not have this allergy indicated on her meal tray ticket, and was not provided with a protein substitute at breakfast when eggs were omitted. Multiple staff confirmed the allergy should have been marked on the tray ticket, and facility policy required both documentation and appropriate food substitutions for allergies and intolerances.
Two residents had inaccurate MDS assessments: one was incorrectly documented as discharged to a hospital instead of another SNF, and another did not have an active anxiety diagnosis listed despite clinical records and medication use for anxiety. These errors resulted in discrepancies between the MDS and other clinical documentation, as confirmed by staff interviews and record reviews.
A resident with mobility impairments and multiple medical conditions was discharged without her rollator walker, and there was no documented follow-up or timely replacement of the missing mobility aid, despite facility policy requiring provision of necessary adaptive equipment.
A resident with severe cognitive impairment was transferred to a new facility without being provided comprehensive information about the new location, as required by the facility's discharge policy. The Social Services Director informed the resident and their responsible party about the transfer but failed to include details about the services, quality measures, or care providers at the new facility, leading to a deficiency.
A facility failed to obtain informed consent from a resident's responsible party for the administration of Olanzapine, an antipsychotic medication. The resident, with diagnoses of psychosis and epilepsy, received the medication for six days without consent. The oversight was confirmed through record reviews and staff interviews, revealing a breach in the facility's policy requiring informed consent for psychotropic medications.
The facility failed to develop person-centered care plans for seven residents, including those with diabetes, psychotropic medication needs, viral hepatitis C, and UTIs. This deficiency involved the absence of care plans for insulin use, psychotropic medications, and antibiotic treatments, which are crucial for outlining interventions and ensuring appropriate care. The oversight was confirmed by the ADON and DON, who acknowledged the importance of care plans in managing residents' specific medical needs.
A resident with severe cognitive impairment was left with unattended medications, violating facility policy requiring nurse supervision during administration. Another resident's bed was not kept in the lowest position as ordered for fall prevention, and a high-risk resident lacked prescribed landing mats, both increasing fall risk. These deficiencies highlight lapses in following physician orders and facility policies.
A facility failed to document attempts of non-pharmacological interventions before administering prn opioid medications to a resident with polyneuropathy and chronic pulmonary edema. Despite physician orders for hydrocodone-acetaminophen, there was no documentation of non-drug interventions being tried first. Interviews with staff confirmed the lack of documentation, highlighting the importance of non-pharmacological measures to prevent unnecessary opioid use and potential side effects.
A resident with multiple health conditions did not receive her medications on time due to a nurse leaving them unattended at the bedside. The nurse became distracted by another resident, resulting in the resident not being observed taking her medications. This incident was against the facility's protocol, which requires medications to be administered within a specific timeframe and the resident to be observed to ensure ingestion.
The facility failed to maintain proper infection control practices for three residents, leading to potential contamination of medical equipment. A resident's catheter tubing was found touching the floor, another's oxygen equipment was improperly labeled and stored, and a third resident's nasal cannula tubing was inside a trash bin. These practices were against the facility's infection control policies and posed a risk of infection.
The facility failed to ensure call lights were within reach for two residents, potentially delaying necessary care. One resident with COPD and coordination issues had a call light placed out of reach, despite requiring assistance with daily activities. Another resident with epilepsy and asthma had a call light hanging behind the bed, making it inaccessible. Both cases were confirmed by CNAs, and the DON highlighted the importance of accessible call lights to prevent falls.
A resident with severe cognitive impairment and requiring gastrostomy care did not receive full privacy during medication administration. LVN 3 left the privacy curtain partially open, violating the facility's policy on dignity and privacy. The DON emphasized the importance of privacy to protect resident dignity.
The facility failed to discard two bags of hotdog buns that were 12 days past their best by date, as observed during a kitchen inspection. A kitchen supervisor confirmed the buns were unsafe for consumption, which could have exposed 24 residents to foodborne illnesses. The facility's policy requires compliance with safe food handling practices.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential delays in care. One resident's MDS incorrectly indicated no falls despite a documented fall, while another's inaccurately reflected the presence of an advance directive. These errors were identified during reviews with an LVN, who stressed the importance of accurate MDS coding for proper care planning. The DON also emphasized the need for accurate assessments to affect residents' care plans.
A resident with impaired cognition and schizophrenia physically assaulted another resident with similar cognitive impairments, resulting in a cut, redness, and swelling around the victim's left eye. The incident was witnessed by an LVN who intervened, but the facility's failure to prevent the altercation violated its abuse prevention policy. The DON and AIT confirmed the incident as physical abuse.
The facility staff failed to follow the smoking policy when one resident shared a cigarette with another, both of whom have moderately impaired cognition and require assistance with mobility. Despite the policy prohibiting such actions, the staff member present did not prevent the sharing, which was confirmed by interviews with multiple staff members.
Failure to Timely Honor Resident Request for Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to be treated with respect and dignity by not completing a requested room change in a timely manner. The resident was admitted with encephalopathy, depression, and dementia, and while a History and Physical documented capacity to understand and make decisions, a subsequent MDS showed severely impaired cognition and a need for moderate to maximal assistance with ADLs. The resident’s responsible party reported requesting a room change from Social Services on 1/8/2026 because the resident felt uncomfortable in the current room, and Social Services confirmed that a suitable room was available and agreed to the change. Social Services staff stated they informed the RN Supervisor of the room change request on the same day but were unsure why the transfer was not completed. The RN Supervisor acknowledged being informed of the request and stated the room change was not done because it was very busy during change of shift, and further acknowledged that the room change should have been completed as soon as possible. The DON confirmed that when a room change is requested, it is to be discussed with social services, the DON, and the admissions coordinator, and that a room was available for this resident at the time of the request and the change should have occurred as soon as possible. Review of facility policies on Resident Rights and Room Change/Roommate Assignment showed that residents are to be treated with kindness, respect, and dignity, and that room changes are to be made when the resident requests them, which did not occur in this case.
Unauthorized Disclosure of a Resident's Medical Records to Another Resident's Representative
Penalty
Summary
The facility failed to maintain privacy and confidentiality of a resident's personal and medical records when the Social Services Director (SSD) provided the wrong chart to another resident's responsible party. Resident 2, who had been admitted with a lumbar vertebral fracture, type 2 DM, COPD, and dementia, had documentation indicating severely impaired cognition and a lack of decision-making capacity. Resident 1, admitted with encephalopathy, depression, and dementia, also had severely impaired cognition but was documented in the H&P as having capacity to understand and make decisions. During a meeting, Responsible Party 1 (RP 1) requested medical records for Resident 1, and the SSD printed records from the printer and handed them to RP 1 without verifying that they belonged to the correct resident. RP 1 later informed the facility that the records received were for a different resident, identified as Resident 2. Interviews with the Medical Records Director (MRD) and the Director of Nursing (DON) revealed that facility policy required any requester of medical records to complete an Authorization for Release of Records, which must be reviewed and approved by the MRD, DON, and Administrator before records are released. The MRD and DON both stated that the SSD should not have provided Resident 2's medical records to RP 1 and that the established authorization and review process was intended to prevent disclosure of records to the wrong recipient. Review of facility policies on release of records and resident rights confirmed that records are to be released only upon properly completed authorization and that residents have rights to privacy and confidentiality of their records.
Failure to Provide Appropriate Oxygen Therapy for Resident with Low Oxygen Saturation
Penalty
Summary
Facility staff failed to provide respiratory care services consistent with professional standards of practice for a resident with a history of respiratory failure, prostate cancer, and dementia. The resident, who had severely impaired cognition and required significant assistance with daily activities, was admitted with physician orders to receive oxygen at 2 to 5 liters per minute (LPM) via nasal cannula, with instructions to titrate oxygen if saturation fell below 90%. On the morning in question, the resident was documented to have an oxygen saturation level of 80% while receiving oxygen via nasal cannula. Despite the low oxygen saturation, there was no documented evidence that staff increased the oxygen flow rate or administered high concentration oxygen using a non-rebreather mask prior to the arrival of paramedics. Interviews with the DON and a registered nurse confirmed that the resident continued to receive oxygen at 5 LPM via nasal cannula and was not switched to a non-rebreather mask. The facility's own policy required staff to adjust oxygen delivery devices and flow rates as needed and to document all assessment data and interventions, but this was not done in this case. When paramedics arrived, they found the resident with an oxygen saturation of 83% on 4 LPM via nasal cannula, a heart rate of 122, and a respiratory rate of 41. Paramedics questioned facility staff about the lack of appropriate oxygen therapy, but no explanation was provided. The paramedics then administered oxygen at 15 LPM via non-rebreather mask and provided additional care before transferring the resident to the hospital.
Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medication use by not meeting required conditions for prescribing and monitoring these medications. For one resident with dementia and mood disturbance, Seroquel was prescribed for 'psychosis manifested by sudden anger outburst' without documentation that the symptoms were due to mania, psychosis, or delusions, or that the behaviors presented a danger to the resident or others. There was also no evidence that the symptoms were not due to a medical condition expected to resolve, or that non-pharmacological interventions had been attempted and found ineffective. The resident’s family member, who was the primary decision maker, refused a gradual dose reduction despite recommendations from the pharmacist and nurse practitioner, and staff interviews indicated the resident’s behaviors were limited to yelling or screaming, with no significant aggression or danger noted. Another resident with cognitive and coordination deficits was prescribed Ativan on an as-needed basis for anxiety manifested by agitation and verbal aggression. The physician’s order required that non-pharmacological interventions be attempted prior to medication administration. However, documentation showed that Ativan was administered without any record of such interventions being tried first, contrary to the order and facility policy. The DON confirmed that non-pharmacological approaches should have been attempted and documented before medicating the resident. A third resident with generalized anxiety disorder and bipolar disorder was prescribed Clonazepam for anxiety. Behavioral monitoring was not initiated at the start of medication administration, and for several weeks, there was no documentation of behavioral assessments prior to giving the medication. The RN and DON both acknowledged that behavioral monitoring should have started with the initiation of Clonazepam, and that the lack of documentation meant the medication was being administered without an indication. Facility policy required monitoring for effectiveness and adverse consequences of psychotropic medications, which was not followed in this case.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care was provided to prevent a decline in these areas unless such decline was due to a documented medical reason. The report notes that the necessary interventions or services to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Act on Pharmacist Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to ensure that recommendations from the consultant pharmacist's monthly Medication Regimen Review (MRR) were acted upon for three residents. For one resident prescribed Quetiapine, the pharmacy recommended an EKG to monitor for potential cardiac effects, but the EKG was not completed as ordered. Both the registered nurse and the assistant director of nursing confirmed that the EKG was missed and not documented in the resident's record, despite the pharmacy's recommendation and the facility's policy requiring such follow-up. Another resident was prescribed Seroquel for psychosis manifested by sudden anger outbursts. The consultant pharmacist recommended ensuring proper documentation for the use of Seroquel, including evidence that the symptoms were due to mania or psychosis, that non-drug interventions had been attempted, and that the behaviors presented a danger or significant distress. The pharmacist also recommended monitoring for orthostatic hypotension and obtaining specific lab tests. The facility did not ensure that these recommendations were followed, and the required documentation and monitoring were not completed in a timely manner. The resident's family member refused a gradual dose reduction, but the facility did not escalate the issue to the medical director as outlined in their policy. A third resident was receiving Klonopin for behavioral control without a documented progress note from the physician explaining why this long-acting benzodiazepine was the best choice. The consultant pharmacist requested updated documentation, but the physician's progress note did not address the rationale for continued use. The director of nursing confirmed that the required documentation was missing, and the resident could be receiving the medication without an appropriate indication. These failures were contrary to the facility's policies and procedures regarding psychotropic medication use and documentation.
Improper Labeling and Storage of Resident Food Brought from Outside
Penalty
Summary
The facility failed to ensure that leftover food brought in by residents' families and visitors was properly labeled with a resident identifier and use-by date before being stored in the resident refrigerator. During an observation with the Administrator in Training (AIT), two plastic bags containing undetermined leftover food were found in the residents' refrigerator at the nurse's station without any labeling or resident identification. The AIT confirmed that the refrigerator is used for storing residents' food and acknowledged that all leftover food should be labeled with an identifier and date. The facility's policy requires perishable foods to be stored in resealable containers with tightly fitting lids, labeled with the resident's name, the item, and the use-by date, and specifies that nursing staff are responsible for discarding perishable foods on or before the use-by date. However, the observed practice did not comply with this policy.
Failure to Accurately Document Clinical Records and Resident Diagnoses
Penalty
Summary
The facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for four residents. Specifically, therapy staff did not accurately document the completion of Rehab Joint Mobility Screens (JMS) for three residents. For each of these residents, the JMS was dated for a specific quarter but was actually completed and signed several months later. The documentation did not indicate that these were late entries, nor did it specify how the range of motion (ROM) measurements were obtained after the fact. Both the co-Director of Rehabilitation and the Assistant Director of Nursing confirmed during interviews that the JMS should have been completed on time, and if late, should have been clearly documented as such with an explanation for the delay and the method of assessment. For one resident, the facility also failed to ensure that a diagnosis of anxiety was included in the resident's medical record, despite evidence in the history and physical, care plan, and psychiatric progress notes that the resident was being treated for anxiety with Ativan. The omission of this diagnosis from the resident's official diagnosis list meant that the medical record did not accurately reflect the resident's conditions or the rationale for prescribed medications. Multiple staff, including the Quality Assurance Nurse, MDS Nurse, and Director of Nursing, acknowledged during interviews that the anxiety diagnosis should have been included in the resident's record to ensure accurate documentation and appropriate care planning. The facility's policy and procedure on charting and documentation, last reviewed in January 2025, requires that all services provided to residents and any changes in their medical or mental condition be documented in the medical record. The failure to accurately document the timing and method of JMS assessments, as well as to include all relevant diagnoses, resulted in incomplete and inaccurate medical records for the affected residents.
Failure to Knock and Request Permission Before Entering Resident Rooms
Penalty
Summary
Facility staff failed to honor residents' rights to dignity and privacy by not knocking or asking permission before entering the rooms of two residents. Both residents had severe cognitive impairments and were totally dependent on staff for activities of daily living. During an observation, a Certified Nurse Assistant (CNA) was seen entering the rooms of these residents without knocking or requesting permission, despite the residents being present in their beds at the time. Upon interview, the CNA acknowledged forgetting to knock and recognized the importance of doing so, as this is considered the residents' home. The Director of Nursing confirmed that facility policy requires staff to knock and request permission before entering any resident's room, emphasizing the need to respect residents' privacy and dignity. A review of the facility's policy further supported this expectation for staff behavior.
Call Light Not Accessible to Resident in Bed
Penalty
Summary
A deficiency was identified when a resident with diagnoses including dysphagia and schizophrenia, and documented impaired cognition, was observed in bed without their call light within reach. The call light was found on the floor, making it inaccessible to the resident. The resident's Minimum Data Set indicated a need for supervision with activities of daily living, highlighting the importance of having the call light accessible for requesting assistance. During the observation, a Certified Nurse Assistant confirmed that the call light should be placed behind the pillow to ensure it is within reach. The Administrator in Training also acknowledged that the call light is the primary means for residents to request help and should always be accessible. Facility policy reviewed stated that the call light must be within easy reach when a resident is in bed or confined to a chair. The failure to ensure the call light was accessible constituted a deficiency in accommodating the resident's needs and preferences.
Failure to Maintain Advance Directives in Resident Medical Charts
Penalty
Summary
The facility failed to ensure that copies of executed Advance Directives (ADs) were kept in the active medical charts and were easily retrievable for two residents. For one resident with diagnoses including dysphagia, type 2 diabetes, and anemia, the admission record and Minimum Data Set (MDS) confirmed the resident was able to communicate and required staff assistance for several activities of daily living. The Advance Directive Acknowledgement (ADA) form indicated that the resident had executed an AD and that the facility had received a copy. However, during a review with the Medical Records Director, it was found that the AD was not present in the resident's chart, despite facility policy requiring it to be accessible in case of emergency. The Assistant Director of Nursing (ADON) confirmed that the AD should have been in the chart to guide staff regarding the resident's wishes. For a second resident with diagnoses including dysphagia, dementia, and anemia, the MDS showed severely impaired cognitive skills and a need for substantial staff assistance. The ADA form and a Physician Orders for Life-Sustaining Treatment (POLST) form both indicated that the resident had executed an AD and that the facility had received a copy. However, during a review with the Social Service Director, it was determined that the AD was not present in the resident's chart. The Social Service Director and the ADON both stated that the AD should have been in the active chart to ensure staff could reference the resident's healthcare wishes. The facility's policy and procedure on Advance Directives, last reviewed in January, required that AD documents be placed in a prominent, accessible location in the medical record and that the resident's wishes be communicated to direct care staff and the physician. In both cases, the facility did not follow its own policy, resulting in the absence of the residents' ADs from their medical charts.
Failure to Include Indwelling Catheter in Baseline Care Plan
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who had an indwelling catheter. Upon review, it was found that the resident was admitted and readmitted with multiple diagnoses, including dysphagia, dementia, obstructive uropathy, and reflux uropathy, and had an order for an indwelling catheter. The resident's assessments and medical records consistently documented the presence of the catheter and the need for substantial assistance with activities of daily living due to severely impaired cognitive skills. Despite this, the baseline care plan created at admission did not include any information regarding the resident's indwelling catheter. Interviews with facility staff, including the MDS nurse and the Assistant Director of Nursing, confirmed that the baseline care plan was incomplete and did not address the catheter, contrary to facility policy and procedure. This omission meant that the resident's immediate care needs related to the indwelling catheter were not documented in the baseline care plan.
Failure to Develop and Implement Person-Centered Care Plans for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents who were prescribed psychotropic medications. For one resident with diagnoses including generalized anxiety disorder and dementia, there was an active order for olanzapine to manage psychosis and agitation. Despite this, a review of the resident's care plans revealed that no care plan was created to address the use of olanzapine, including interventions to prevent or manage potential adverse effects. The Director of Nursing confirmed that a care plan should have been developed to guide staff in managing the medication's side effects. For another resident admitted with major depressive disorder, hypertension, and atrial fibrillation, there was an order for amphetamine-dextroamphetamine to treat ADHD. The resident was assessed as having the capacity to understand and make decisions and was independent in activities of daily living. However, a review of the care plans showed that no care plan was developed for the use of the ADHD medication. Nursing staff acknowledged that a care plan was required for any medication that could alter a resident's mental state, and the Assistant Director of Nursing confirmed that a care plan should have been written for the psychotropic medication. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables for each resident, including those receiving psychotropic medications. The policies also specified that behavioral interventions and monitoring for effectiveness and adverse consequences should be included. The absence of care plans for these medications meant that staff lacked documented guidance for monitoring and managing the residents' medication regimens as required by facility policy.
Failure to Update Dental Care Plan After Loss of Dentures
Penalty
Summary
The facility failed to update and revise a resident's dental care plan after the resident's upper dentures went missing. The resident, who had diagnoses including major depressive disorder, type two diabetes mellitus, and schizophrenia, was noted to have moderately impaired cognitive skills and required staff assistance for various activities of daily living, including supervision for oral hygiene. The resident's care plan for dental problems, initiated at admission, included interventions for daily oral care and dental consultations as needed, and originally indicated the resident was wearing full top dentures. After the resident reported her top dentures missing, documentation showed that a dental evaluation was performed and extractions were recommended to prepare for new dentures, but the resident declined further dental procedures. Despite this significant change, the care plan was not reviewed or revised to reflect the loss of the dentures or the resident's decision to decline further dental treatment. Interviews with facility staff confirmed that care plans are required to be reviewed and updated quarterly and after significant changes, but this was not done in this case.
Failure to Complete and Accurately Document Fall Risk Assessments After Resident Falls
Penalty
Summary
The facility failed to ensure that fall risk assessments were completed accurately and in a timely manner for two residents, resulting in deficiencies related to accident prevention and supervision. For one resident, who had diagnoses including metabolic encephalopathy, lack of coordination, and mild cognitive impairment, the facility did not accurately document a fall that occurred. Despite the resident being found on the floor next to her bed, the subsequent fall risk assessments incorrectly indicated that she had not fallen in the previous 90 days. Both the registered nurse and the director of nursing confirmed that this omission was incorrect and could affect the accuracy of the fall risk score. Another resident, admitted with unspecified dementia, Alzheimer’s disease, and lack of coordination, experienced a witnessed fall when sliding from a wheelchair to the floor. However, after this incident, licensed staff did not complete a fall risk assessment as required by facility policy. Both the MDS nurse and the assistant director of nursing acknowledged that a fall risk assessment should have been completed after the fall, in accordance with the facility’s procedures for assessing falls and their causes. The facility’s policies and procedures specify that after a fall, staff must complete a fall risk assessment, document appropriate interventions, and record relevant information in the resident’s medical record. In both cases, the failure to follow these procedures resulted in incomplete or inaccurate documentation of fall risk, which could impact the identification and implementation of interventions to prevent further falls.
Failure to Document Post-Dialysis Weight for Resident Receiving Hemodialysis
Penalty
Summary
The facility failed to ensure that a post-dialysis assessment was completed for a resident who required hemodialysis. Specifically, the dialysis center did not record the resident's post-dialysis weight on the communication record for a specified date. This omission was verified during record reviews and interviews with both a Licensed Vocational Nurse (LVN) and the Assistant Director of Nurses (ADON), who confirmed that the post-dialysis weight was missing and acknowledged that the nursing staff should have contacted the dialysis center to obtain this information. The resident involved had a diagnosis of end stage renal disease and was dependent on hemodialysis, with a care plan in place that included monitoring weight and reporting significant changes to the physician. The facility's policy required documentation of dialysis treatment in the resident's medical record. Despite these requirements, the absence of the post-dialysis weight was not addressed by the nursing staff, resulting in incomplete documentation of the resident's dialysis care.
Failure to Monitor Stimulant Medication Use and Effectiveness
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not adequately monitoring the use of amphetamine-dextroamphetamine, a stimulant medication typically used to treat ADHD. The resident in question was admitted with diagnoses including major depressive disorder, hypertension, and unspecified atrial fibrillation, but did not have a documented diagnosis of ADHD. Despite being prescribed amphetamine-dextroamphetamine, there was no corresponding care plan or physician’s order to monitor for adverse effects or effectiveness of the medication. During interviews and record reviews, it was confirmed that nursing staff did not create a care plan or obtain an order to monitor the resident’s behavior or potential adverse effects related to the stimulant medication. Both the registered nurse and the assistant director of nursing acknowledged that such monitoring and care planning were required by facility policy, especially for psychotropic medications. The facility’s policies also specified the need for behavioral interventions and monitoring for effectiveness and adverse consequences, which were not implemented in this case.
Failure to Document and Accommodate Food Allergy and Preferences
Penalty
Summary
The facility failed to properly document and accommodate a resident's egg allergy and food preferences, resulting in deficiencies in care. The resident, who had a documented allergy to eggs in multiple records including the admission record, history and physical, dietary interview, and care plan, did not have this allergy indicated on her meal tray ticket. Observations confirmed that the tray ticket only listed eggs as a dislike, not as an allergy, and staff interviews revealed that the allergy should have been clearly marked to prevent exposure. The dietary supervisor, registered nurse, registered dietician, and director of nursing all acknowledged that the allergy was not properly documented on the tray ticket, which could lead to the resident being served eggs. Additionally, the facility failed to provide an appropriate food substitution for the resident during breakfast when eggs were not served. On observation, the resident's breakfast tray did not contain eggs, but also lacked a protein substitute. The dietary supervisor confirmed that a protein should have been provided in place of the egg and subsequently added yogurt to the tray after the deficiency was noted. The resident expressed a preference for yogurt, and the dietary supervisor emphasized the importance of protein in the diet. The facility's own policy and procedure on food allergies and intolerances required that all resident-reported food allergies be documented in assessment notes, care plans, and diet slips, and that appropriate substitutions be offered for foods that cannot be eaten. Despite these policies, the resident's egg allergy was not properly communicated on the tray ticket, and a suitable substitution was not provided at breakfast, resulting in a failure to meet the resident's nutritional needs and accommodate her allergy.
Inaccurate MDS Assessments for Discharge Disposition and Active Diagnoses
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in inaccurate documentation of their status and diagnoses. For one resident, the MDS assessment incorrectly indicated that the resident was discharged to a short-term general hospital, while multiple other records, including physician orders, nursing progress notes, and the discharge summary, all documented that the resident was actually discharged to another skilled nursing facility. The MDS nurse responsible for completing the assessment acknowledged that the wrong discharge disposition was selected in error, leading to an inaccurate medical record. For another resident, the MDS assessment did not include an active diagnosis of anxiety, despite the resident's history and physical, psychiatric progress notes, and care plan all documenting anxiety as a current condition. The resident was receiving Ativan for anxiety, and the care plan specifically addressed interventions for anxiety-related behaviors. The MDS nurse confirmed that anxiety should have been included as an active diagnosis in the MDS to ensure accurate documentation of the resident's medications and diagnoses. Facility policy requires that MDS assessments be completed accurately and reflect information consistent with progress notes, care plans, and resident observations. The deficiencies identified were due to staff errors in completing the MDS, resulting in discrepancies between the MDS and other clinical documentation for both residents.
Failure to Provide Medically-Related Social Services: Missing Mobility Aid at Discharge
Penalty
Summary
The facility failed to provide medically-related social services to meet the needs of a resident by not ensuring the return or timely replacement of a missing rollator walker, a mobility aid necessary for safe ambulation. The resident, who had diagnoses including systemic lupus erythematosus, cerebral infarction, and difficulty walking, was admitted with a documented need for assistance with mobility and other activities of daily living. Upon discharge, the inventory list indicated the resident had a walker, but there was no documentation or signatures confirming the walker was returned to the resident. A review of records and interviews with the Social Services Assistant confirmed that the resident was discharged without her rollator walker and that there was no documented follow-up to obtain or replace the missing equipment. The facility's policy required the provision of adaptive equipment to maintain or improve residents' physical and psychosocial needs, but this was not followed in this case.
Inadequate Discharge Planning for Resident Transfer
Penalty
Summary
The facility failed to ensure proper discharge planning for a resident, resulting in a deficiency. The resident, who had severe cognitive impairment and required maximum assistance for daily activities, expressed a desire to transfer to another facility. The Social Services Director (SSD) assisted in finding a new facility and informed the resident and their responsible party (RP) about the transfer. However, the SSD did not provide comprehensive information about the new facility, such as the services offered, quality measures, or details about the care providers, which is required by the facility's discharge policy. The Director of Nursing (DON) confirmed that the correct process for transferring a resident includes providing detailed information about the new facility to the resident and their RP. The facility's policy on discharging residents outlines the need to inform them about the location, size, services, and care providers at the new facility, as well as the reason for the discharge. The failure to provide this information could potentially lead to decreased quality of care and continuity of care for the resident.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident's responsible party (RP) for the administration of the antipsychotic medication Olanzapine. This oversight involved a resident who was originally admitted with diagnoses including psychosis and epilepsy. The resident's Minimum Data Set indicated intact cognition and required assistance with various activities of daily living. Despite these needs, the facility administered Olanzapine for six days without obtaining the necessary informed consent from the RP, as documented in the resident's records. The deficiency was identified during a review of the resident's physician orders and informed consent forms, which showed that consent was obtained for other medications but not for Olanzapine. Interviews with a registered nurse and the administrator in training confirmed that the medication was started at the hospital and continued upon the resident's return to the facility without proper consent. The facility's policy requires informed consent for psychotropic medications, but this was not adhered to in this case, resulting in the administration of Olanzapine without the RP's informed agreement.
Failure to Develop Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans for seven residents, leading to deficiencies in addressing their specific medical needs. For three residents with diabetes, the facility did not create care plans for their insulin use, despite having physician's orders for insulin administration. This oversight was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), who acknowledged the absence of care plans that should have included treatment goals, specified interventions, and evaluation dates. Another resident, who was readmitted with bipolar disorder and unspecified psychosis, was prescribed psychotropic medications such as Latuda, Seroquel, and Trazodone. However, the facility did not develop care plans for these medications, which are crucial for monitoring drug risks and ensuring the resident's care needs are met. The DON emphasized the importance of care plans in recognizing the right interventions for specific medications to manage the resident's behaviors effectively. Additionally, the facility failed to create care plans for a resident diagnosed with viral hepatitis C and two residents with urinary tract infections (UTIs) who were on antibiotics. The lack of care plans for these conditions meant that necessary interventions, goals, and communication with the care team were not outlined. The DON highlighted that care plans are essential for detailing interventions and treatments based on residents' diagnoses and medications, ensuring appropriate care and effective communication among the care team.
Medication and Fall Prevention Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper supervision during medication administration for a resident with severe cognitive impairment. The resident was found with several medications left unattended on the bedside table, which were supposed to be administered at 9 a.m. The nurse responsible for administering the medications became distracted and left the medications without witnessing the resident take them. This oversight was acknowledged by the nurse and the Director of Nursing, who confirmed that the resident was not authorized to self-administer medications, and the facility's policy required nurses to observe residents taking their medications. Another deficiency involved a resident whose bed was not positioned in the lowest position as ordered by the physician for fall prevention. The resident had a history of falls and required assistance with daily activities. A Certified Nursing Assistant admitted to not following the physician's order because it was easier for the resident to stand up from a higher bed position. The Director of Nursing emphasized the importance of following physician orders to potentially reduce the severity of injuries from falls. The facility also failed to provide a high-risk resident with bilateral landing mats as ordered by the physician. The resident, who had fluctuating capacity and required assistance with mobility, was observed without the prescribed landing mats in her room. The Director of Staff Development confirmed the absence of the mats and acknowledged that no other interventions were in place to prevent falls, despite the resident's high fall risk score. The facility's policy required the implementation of a resident-centered fall prevention plan, which was not adhered to in this case.
Failure to Document Non-Pharmacological Interventions Before Opioid Administration
Penalty
Summary
The facility failed to ensure that licensed nurses documented attempts of non-pharmacological interventions before administering as-needed opioid medications to a resident. This deficiency was identified for one of the 30 sampled residents, who was admitted with diagnoses including polyneuropathy and chronic pulmonary edema. The resident had moderately impaired cognition and required partial assistance for most activities of daily living. The physician's orders included hydrocodone-acetaminophen for moderate pain, but there was no documentation of non-pharmacological interventions being attempted prior to administering the medication on multiple occasions. During interviews, the Licensed Vocational Nurse and the Director of Nursing acknowledged the absence of documentation for non-pharmacological interventions before administering the opioid medication. The Director of Nursing emphasized the importance of attempting such interventions to avoid unnecessary reliance on opioid medications, which could lead to adverse side effects like increased risk for falls and sedation. The facility's policy on pain assessment and management, last reviewed in January 2024, indicated that non-pharmacological interventions might be appropriate alone or alongside medications.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the late administration of several medications for a resident with end-stage renal disease and severely impaired cognition. The resident was readmitted to the facility with multiple diagnoses, including seizure disorder, unspecified psychosis, restless leg syndrome, bipolar disorder, Parkinson's disease, and hypertension. The physician had ordered specific medications to be administered at designated times to manage these conditions. On the day of the incident, a registered nurse observed a cup of medications left on the resident's bedside table, which were supposed to be administered at 9 a.m. The nurse acknowledged that the medications should not have been left unattended and that the nurse should have ensured the resident took them. A licensed vocational nurse admitted to leaving the medications at the bedside due to being distracted by another resident needing assistance, resulting in the resident not being observed taking the medications. The facility's Director of Nursing confirmed that the medications were administered late, outside the standard protocol of administering 9 a.m. medications between 8 a.m. and 10 a.m. The facility's policy and procedure for medication administration emphasized the importance of administering medications without unnecessary interruptions and observing the resident to ensure the medications were ingested. The failure to adhere to these procedures resulted in the resident receiving her medications late, with the potential for missed doses.
Infection Control Deficiencies in Equipment Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for three residents, leading to potential contamination of medical equipment. For Resident 279, the indwelling catheter tubing was observed touching the floor, which was acknowledged by a Certified Nursing Assistant (CNA) and the Infection Preventionist Nurse (IPN) as a risk for infection due to the floor's contamination. The facility's policy clearly stated that catheter tubing and drainage bags should be kept off the floor. Resident 7's oxygen equipment was not properly labeled or stored, as observed by a Registered Nurse (RN). The nasal cannula was found touching the floor, and both the humidifier and nasal cannula were unlabeled. The Director of Nursing (DON) confirmed that labeling and proper storage are necessary to prevent infection, as per the facility's policy on respiratory therapy infection prevention. For Resident 117, a portion of the nasal cannula tubing was found inside a trash bin, which the Assistant Director of Nursing (ADON) identified as a contamination risk. The facility's infection control policy emphasized maintaining a safe and sanitary environment to prevent disease transmission. The Centers for Disease Control and Prevention (CDC) guidelines also highlighted the rapid contamination potential of floors, reinforcing the need for proper infection control measures.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, which could delay necessary care and services. Resident 27, who was admitted with chronic obstructive pulmonary disease, difficulty in walking, and lack of coordination, was observed with a call light placed on the top edge of the bed, out of reach. The resident required assistance with various activities of daily living and did not have the capacity to understand and make decisions. The care plan for Resident 27 included an intervention to keep the call light within reach, but this was not followed. A Certified Nursing Assistant confirmed the call light's placement and acknowledged the importance of having it within reach to prevent falls. Similarly, Resident 28, diagnosed with epilepsy and asthma, was found with a call light hanging behind the bed, making it inaccessible. This resident also had moderately impaired cognition and required supervision for most activities of daily living. The care plan for Resident 28 included ensuring the call light was within reach, but this was not adhered to. A Certified Nursing Assistant confirmed the call light's improper placement. The Director of Nursing emphasized the importance of having call lights within reach to prevent residents from attempting to perform tasks unassisted, which could lead to falls.
Failure to Ensure Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure privacy for a resident during medication administration via a gastrostomy tube, which violated the resident's right to privacy. Licensed Vocational Nurse 3 (LVN 3) was observed administering medications to Resident 62 without fully closing the privacy curtain around the resident's bed, leaving it open at the foot. This action was confirmed during an interview with LVN 3, who acknowledged not closing the curtain completely. Resident 62 was admitted to the facility with diagnoses including aphasia, hemiplegia, hemiparesis, and required attention to a gastrostomy. The resident had severely impaired cognition and needed maximal assistance for most activities of daily living. The facility's policy on dignity, last reviewed in January 2024, emphasized the importance of maintaining resident privacy during personal care and treatment procedures. The Director of Nursing also highlighted the significance of providing privacy to protect residents' dignity and prevent embarrassment.
Expired Food Handling Deficiency
Penalty
Summary
The facility failed to adhere to safe food handling practices by not discarding two bags of hotdog buns that were 12 days past their best by date. During a kitchen observation, a kitchen supervisor acknowledged the presence of the expired buns and stated that they were no longer safe for consumption by residents. The facility's policy on food receiving and storage, which was last reviewed earlier in the year, mandates that food should be received and stored in compliance with safe food handling practices. This oversight had the potential to expose 24 out of 121 residents to foodborne illnesses due to the consumption of potentially contaminated food.
Inaccurate MDS Assessments for Falls and Advance Directives
Penalty
Summary
The facility failed to ensure accurate assessments in the Minimum Data Set (MDS) for two residents, leading to potential delays in care and services. For one resident, the MDS inaccurately indicated that the resident had no falls since admission, despite a documented fall occurring on 3/25/2024. This resident had severely impaired cognition and required substantial assistance for activities of daily living. The inaccuracy was identified during a review with a Licensed Vocational Nurse (LVN), who acknowledged the error and emphasized the importance of accurate MDS coding for proper care planning. Another resident's MDS inaccurately reflected the presence of an advance directive, which was not the case according to the resident's Advance Directive/Physician Orders for Life-Sustaining Treatment Acknowledgement form. This resident had intact cognition and required moderate assistance for daily activities. The LVN confirmed the MDS error and highlighted the significance of knowing whether a resident has an advance directive to ensure care aligns with the resident's preferences, especially if the resident loses decision-making capacity. The Director of Nursing reiterated the importance of accurate MDS assessments for effective care planning.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident hit another, resulting in physical injuries. On the specified date, Resident 1, who had diagnoses including seizures and schizophrenia and was noted to have severely impaired cognition, physically assaulted Resident 2. This incident occurred despite Resident 1's known inability to understand or make decisions independently, as documented in their medical records. Resident 2, who also had severely impaired cognition due to dementia and schizophrenia, sustained a cut, redness, and swelling around the left eye as a result of the altercation. The incident was witnessed by an LVN, who intervened to separate the residents. The LVN observed that Resident 2 had discoloration around the left eye, which was not present before the altercation, indicating that Resident 1 likely hit Resident 2 during the struggle. The facility's Director of Nursing and the Administrator in Training confirmed that the incident constituted physical abuse and acknowledged that the facility failed to protect Resident 2 from such abuse. The facility's policy on abuse prevention, which mandates that residents be free from abuse, was not followed, as evidenced by the failure to prevent the altercation and subsequent injury to Resident 2.
Failure to Enforce Smoking Policy
Penalty
Summary
The facility staff failed to follow the facility's smoking policy for two residents when they allowed one resident to share a cigarette with another. Resident 3, who has moderately impaired cognition and requires moderate assistance with mobility, was observed giving a cigarette to Resident 4, who also has moderately impaired cognition and requires supervision with mobility. This incident occurred in the smoking patio, and the staff member present, referred to as Gatekeeper, did not prevent the sharing of the cigarette despite knowing that it was against the facility's policy. Interviews with the Gatekeeper, Activities Supervisor, and Director of Nursing confirmed that the facility's policy prohibits residents from sharing smoking items. The facility's policy, titled 'Smoking Policy - Residents,' explicitly states that residents are not permitted to give smoking items to other residents. The failure to enforce this policy has the potential to place residents at risk for accidents such as burns.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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