Sundance Creek Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Banning, California.
- Location
- 5800 West Wilson Street, Banning, California 92220
- CMS Provider Number
- 555309
- Inspections on file
- 42
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Sundance Creek Post Acute during CMS and state inspections, most recent first.
A resident with cognitive impairment and lower extremity wounds experienced documented deterioration of diabetic heel wounds and new discoloration on the dorsum of the foot over several occasions. Although COC notes showed that physicians were notified and the resident was informed, the resident’s designated representative was not notified, despite facility policy and staff acknowledgment that changes in condition should be communicated to the resident representative and documented accordingly.
Two residents were involved in a physical altercation when a cognitively impaired resident with delusional and impulse disorders, known to wander and enter others’ rooms, went into another resident’s room, attempted to take personal items, and punched the resident in the face, causing minor injuries. The aggressive resident’s care plan identified risk for elopement and wandering but contained only general interventions without specifying the level of supervision or monitoring required, despite a physician order to monitor for impulse control disorder with wandering and danger to self and others. Staff, including an RN, LVN, and CNAs, reported awareness of the resident’s wandering and occasional aggression but were unaware of specific written interventions, there was no documented CNA monitoring of wandering behavior, and the resident was not listed on the facility’s internal communication board as at risk for wandering at the time of the incident.
Two residents with significant mobility impairments were unable to have their transfer needs and preferences met due to an insufficient number of Hoyer lifts. This resulted in delays, missed activities, and disruption of daily routines, as confirmed by staff and resident interviews and record reviews.
A resident with a history of diabetes, end stage renal disease, and hemodialysis was not assessed or monitored for circulatory insufficiency after a DVT diagnosis, despite care plan interventions and facility protocols requiring monitoring for pain, swelling, discoloration, and pedal pulses. Nursing staff and the DON confirmed that no documentation of such monitoring existed, and the deficiency was identified after the resident developed necrosis and was hospitalized for gangrene.
A resident with diabetes and fluctuating capacity experienced significant changes in skin condition, including a reclassified sacral pressure wound and new deep tissue injuries, as identified by wound care specialists. Despite these findings and new treatment orders, nursing staff did not complete required skin and wound evaluations or update the weekly summaries to reflect these changes, resulting in incomplete and inaccurate medical records. Both the LVN and DON confirmed that documentation should have included updated wound descriptions and measurements, in accordance with facility policy.
A resident with severe cognitive impairment and communication challenges was allegedly struck by another resident with a mental health disorder. The incident was witnessed by a third resident and reported to nursing staff, but the required report to CDPH and the Ombudsman was not made within the mandated two-hour timeframe. Staff interviews revealed miscommunication and lack of follow-through, resulting in delayed notification to the DON and failure to comply with facility policy.
A resident with fluctuating capacity to make medical decisions experienced a right shoulder prosthesis dislocation, an injury of unknown source, which was not reported to CDPH, police, or the Ombudsman within the required two-hour timeframe. Despite facility policy mandating immediate reporting to rule out abuse, the incident was not communicated as required, potentially affecting the resident's well-being.
A resident experienced a dislocation of their right shoulder prosthesis, which was not investigated by the facility despite being an injury of unknown origin. The resident was admitted without initial shoulder issues, but later complained of pain and swelling, leading to an X-ray that confirmed the dislocation. The facility's policy requires investigations for such injuries, but no investigation was conducted, as confirmed by the DON.
A resident with fluctuating decision-making capacity was transferred to a hospital without receiving a written transfer notice, and the LTC Ombudsman was not informed. The facility's policy requires such notices to be provided to both the resident and the Ombudsman, but this was not documented or executed.
A resident with significant mobility impairments and a history of stroke did not receive scheduled showers or bed baths as per their care plan. Despite being dependent on assistance for all ADLs, documentation showed missed showers and bed baths on several occasions, with no record of refusal. Interviews with staff and the DON confirmed lapses in following the care plan and documentation protocols.
A resident with hemiplegia and high risk for pressure ulcers was not repositioned every two hours as required, leading to the development of a pressure ulcer. Facility staff failed to document repositioning, and there was no schedule in place to ensure compliance with the facility's policy.
A resident reported missing finances, including a bank card and $600, to a Social Service Assistant (SSA) in an LTC facility. The SSA failed to report the financial abuse allegation to the California Department of Public Health (CDPH) within the required two-hour timeframe, instead reporting it 25 hours later. The facility's policy mandates immediate reporting of such incidents to ensure resident safety and prevent further abuse.
A resident was not monitored for emotional and psychosocial wellbeing after reporting financial abuse by a family member. Despite the facility's standard practice of 72-hour monitoring following abuse allegations, this was not conducted, and there was no specific policy to ensure such monitoring.
A Physical Therapy Assistant in an LTC facility failed to perform hand hygiene when entering and exiting the rooms of two residents under Droplet Precaution. Despite facility policies and signage requiring hand hygiene to prevent infection spread, the PTA did not comply, as confirmed by the Infection Preventionist.
A resident's family member filed a grievance about the resident being left unattended in a shower. The facility investigated the complaint but failed to document the investigation or inform the family member of the findings, contrary to their grievance policy. The resident had severe cognitive impairment, making family communication essential.
A resident was issued an incomplete discharge notice, lacking the discharge date and location, due to the Social Service Director leaving these fields blank as the resident had not decided on his next living arrangement. The resident, unable to read the notice due to poor eyesight, was unaware of his discharge location, leading to a deficiency in the facility's compliance with notification requirements.
A resident with Type II Diabetes Mellitus and Essential Hypertension did not receive a follow-up ophthalmology consult, as required by their care plan. Despite the resident's capacity to make decisions and their expressed need for an ophthalmologist, the Social Service Director failed to arrange the necessary appointment, as confirmed by interviews with the Director of Nursing and the SSD.
The facility failed to document the administration of narcotic pain medications for 20 residents, leading to potential discrepancies and possible diversion of controlled substances. Licensed nurses signed out medications but did not consistently document their administration in the eMAR, affecting residents with conditions like muscle wasting and chronic pain. Interviews with LVNs confirmed the lack of documentation, highlighting a failure to follow the facility's process for administering PRN narcotic pain medications.
A facility with 132 beds failed to employ a qualified full-time social worker. The Social Service Director lacked the necessary bachelor's degree and was not a licensed medical social worker, nor supervised by one. This deficiency was confirmed by the Administrator, contradicting the facility's job description and policy requirements.
The facility failed to ensure effective narcotic medication accountability and pain assessment. Narcotic medications were signed out by LNs but not documented in the e-MAR, and pain assessments were not conducted after medication administration. Despite identifying these issues, the facility did not monitor or re-evaluate the effectiveness of interventions, risking medication diversion and unmanaged pain.
The facility failed to promptly respond to call lights for several residents, with wait times ranging from 10 to 30 minutes, despite previous discussions in Resident Council meetings. Additionally, a resident consistently received her meal after another resident, impacting her dignity and meal intake. Staff interviews confirmed the expectation for prompt response and simultaneous meal service, but these were not met.
The facility failed to conduct self-administration assessments for three residents, leading to medications and supplements being left at their bedsides without proper authorization or physician orders. LVNs acknowledged the oversight, and the DON emphasized the importance of following facility policies to ensure safe medication administration.
The facility failed to provide education and resources for Advance Directives (AD) to 15 residents and their representatives, as required by policy. Despite some residents having the capacity to make decisions, there was no documentation of AD education in their records. The Social Service Director admitted to not providing the necessary education or follow-up, resulting in a deficiency.
The facility failed to conduct pain assessments and evaluate the effectiveness of PRN narcotic pain medications for 20 residents, including those with osteomyelitis, diverticulosis, and chronic pain syndrome. Licensed nurses did not document pain levels before or after administering medications like Tramadol and oxycodone-acetaminophen, compromising effective pain management.
The facility failed to ensure Food and Nutrition Service employees followed proper procedures, leading to deficiencies. Employees did not clean kitchen equipment correctly, using only sanitizer instead of detergent and sanitizer. Staff also misunderstood the correct chlorine concentration for dish machines, risking cross-contamination. Additionally, a cook did not follow a recipe for pureed Bread Stuffing, resulting in overly salty servings for residents on a pureed diet.
The facility failed to provide appetizing food at appropriate temperatures, affecting nine residents. Observations and interviews revealed issues such as cold meals, bland and tough meat, and improperly seasoned pureed meals. A test meal evaluation confirmed that food temperatures did not meet policy standards, with cold items served warmer and hot items cooler than required. The meal service process was inefficient, contributing to these discrepancies.
The facility failed to maintain sanitary conditions in the kitchen, with mold, dust, and hair found in the walk-in refrigerator, calcium buildup on the hot water spout, and wet containers improperly stored. Dust and rust were observed on equipment, and chipped paint was noted on a mixer and utensil hanger. An unsanitary microwave was also found, posing a risk of contamination.
A resident with hypotension experienced disturbances during sleeping hours due to noise from another resident gardening early in the morning. Despite multiple complaints, the facility failed to maintain a quiet environment, as confirmed by an LVN and acknowledged by the DON. The facility's policy emphasized the need for comfortable noise levels to ensure a homelike setting.
A resident with pulmonary hypertension was not accurately assessed for smoking habits, despite admitting to occasional smoking and being observed by staff. The facility's smoking policy was not followed, as the resident's use of electronic cigarettes was not documented or assessed for safety, posing potential injury risks.
A resident with respiratory issues was receiving oxygen at 4 LPM instead of the prescribed 2 LPM, as observed during an interview with an LVN. The incorrect flow rate was confirmed by an RN, who noted the potential for oxygen toxicity. The facility's policy requires verification of physician orders for safe oxygen administration, which was not followed.
The facility failed to provide proper post-dialysis assessment for a resident with ESRD and did not follow a physician's order to discontinue fluid restriction for another resident. The lack of post-dialysis assessment and incomplete I&O monitoring documentation were confirmed by staff, indicating a failure to adhere to facility policies and physician recommendations.
A resident with schizophrenia was prescribed Olanzapine for auditory hallucinations, but the LTC facility failed to monitor the resident's behavior as required. The Director of Nursing confirmed the absence of a care plan for the resident's hallucinations, despite facility policies mandating such monitoring and care planning.
The facility failed to properly store discontinued medications, as two vials of Lorazepam and an Insulin Lispro Injection pen marked as discontinued were found in the medication room refrigerator. The RN stated that these medications should have been discarded by the night shift nurses, while the DON confirmed that discontinued medications should be placed in a discontinue bin and destroyed monthly with the pharmacist consultant.
A resident with End-Stage Renal Disease did not receive meals according to the physician's NAS diet order, which included specific food preferences and restrictions. The dietary department failed to adhere to these instructions, serving meals with items the resident disliked. Additionally, the RD's recommendation to fortify the resident's diet due to weight loss was not communicated to the physician or implemented, contrary to facility policy.
A CNA failed to disinfect a Hoyer lift between resident uses, and an RN did not wear PPE while caring for a resident with an ESBL infection. Both actions were against the facility's infection control policy, risking the spread of infection.
The facility failed to maintain an effective pest control program, leading to house flies being observed in the kitchen and East activity room. A fly was seen on a cleaned container in the kitchen, attributed to a delivery man propping the door open. Another fly was observed on a resident's food in the East activity room, entering when residents opened the door to smoke. The Registered Dietitian confirmed that flies carry bacteria, and the facility's policies emphasize the need for pest control to maintain sanitation standards.
A Treatment Nurse failed to perform hand hygiene between glove changes during wound care for a resident with a sacral wound, contrary to facility policy. The resident had a complex medical history, including a stage 4 pressure ulcer. The Infection Preventionist confirmed the protocol breach.
The facility failed to employ a dedicated Dietary Manager, leading to lapses in food safety practices such as missing use-by dates on food items. Duties were shared among a Dietary Corporate Consultant, a Registered Dietitian, and a DM from a sister facility, resulting in negative impacts on staff work and oversight issues.
The facility failed to store food items according to professional standards, as observed when Italian dressing and egg salad in the refrigerator were missing use-by or expiration dates. The DCC confirmed that all food items should be labeled with these dates, but the dietary staff member responsible for the egg salad forgot to do so. The task of checking expiration dates was not completed due to the absence of a DM, and the DCC had not yet checked the dates upon starting her shift.
A facility failed to ascertain the current condition of a resident before refusing re-admission after hospitalization. The decision was based on the resident's previous behavior and a psychologist's note, without proper follow-up to determine if the behavior had stabilized. This action was contrary to the facility's policy on bed-holds and returns.
The facility failed to provide bed hold information and the Notice of Proposed Transfer/Discharge to a resident's family member after the resident was transferred to a hospital for psychiatric evaluation. The decision to not provide a bed hold was made due to the resident's aggressive behavior, and the facility did not follow up with the hospital to check if the behavior had stabilized.
Failure to Notify Resident Representative of Wound Deterioration
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s designated representative of multiple documented changes in condition related to deteriorating lower extremity wounds. A resident admitted with acute osteomyelitis of the left ankle and foot had a history and physical dated October 7, 2025, indicating a change in cognitive function that affected her ability to make informed medical decisions, and her grandson was designated as the responsible party for medical decision-making. Review of the resident’s change of condition (COC) documentation from November through December 2025 showed that on November 21, 2025, staff noted deterioration of right and left heel diabetic wounds during wound rounds, with the primary care provider notified and the resident updated. On December 5, 2025, the right heel diabetic wound was again documented as deteriorating by a wound specialist, with updated treatment orders and a notation that the family or resident was notified, marked as “self.” On December 8, 2025, during wound care, dark brown/purple discoloration was observed on the right dorsum of the foot, the MD was notified, and documentation again indicated the family or resident was notified, marked as “self.” There was no documented evidence that the resident’s representative was notified of these changes in condition on November 21, December 5, and December 8, 2025. During an interview and concurrent record review, the LVN who completed the COC entries stated she recalled providing wound care and completing the COCs, and explained that the process for communicating a change in condition was to notify the resident, family or resident representative, and the primary care and wound care physicians. She acknowledged that on the three dates in question she notified only the resident and did not notify the resident’s representative, and stated she should have communicated the changes to the representative. In a separate interview and record review, the DON confirmed that the resident experienced changes in condition on those dates and that the resident’s representative should have been notified, consistent with the facility’s policy titled “Change in a Resident’s Condition or Status,” which requires the nurse to notify the resident’s representative and document information related to significant changes in the resident’s condition or status.
Failure to Implement Effective Wandering Interventions Resulting in Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent resident-to-resident physical altercations, specifically related to a resident with known wandering and impulse control issues. One resident with intact decision-making capacity reported that another resident entered his room, attempted to take his cup and blanket, and then punched him twice in the face when he tried to stop the behavior. As a result, he sustained swelling of the right upper lip and a scratch on the nose. He stated that he pressed his call light but did not receive an immediate staff response and had to yell for help before staff intervened. The resident who initiated the altercation had documented diagnoses of delusional disorder and impulse disorder and was noted in the medical record to be unable to make decisions. The care plan for this resident, dated several months prior, identified risk for elopement and wandering related to altered cognitive status and forgetfulness, with a goal that the resident’s safety would not be endangered by these behaviors. However, the care plan only contained a general intervention for elopement/wandering and did not specify the type or level of supervision or monitoring needed to address the resident’s wandering behavior. A physician’s order in the eMAR directed staff to monitor this resident for episodes of impulse control disorder manifested by wandering and danger to self and others, but there was no documentation that such behaviors were monitored or addressed on the date of the incident. Staff interviews further showed gaps in implementation and communication of interventions for the wandering resident. The DON acknowledged that the care plan for elopement and wandering lacked specific prevention interventions and that there was no CNA documentation that monitoring of wandering behavior had been completed. The DON also stated that the internal communication board did not list this resident as at risk for wandering prior to the incident. Nursing staff, including an LVN and the charge RN on duty at the time of the altercation, reported awareness of the resident’s history of wandering into other residents’ rooms and occasional aggression, but were unaware of any written interventions to address this behavior. A CNA assigned to the wandering resident on the evening of the incident stated that the resident frequently wandered and needed to be checked every 15 to 30 minutes, and that while she was on her lunch break, no one was assigned to check on the resident, during which time the altercation occurred.
Failure to Provide Adequate Hoyer Lifts for Resident Transfers
Penalty
Summary
The facility failed to make reasonable accommodations to meet the needs and preferences of two residents who required a Hoyer lift for transfers. Both residents had medical conditions necessitating total assistance with transfers: one with morbid obesity and chronic pain syndrome, and the other with hemiplegia and hemiparesis following a stroke. Observations, interviews, and record reviews revealed that there were only three functioning Hoyer lifts available for over 100 residents, with at least ten residents in one station alone requiring the device. Staff and residents reported frequent delays in transfers due to the limited number of lifts, resulting in residents having to wait for extended periods or missing scheduled activities. Resident A reported disruptions to his established daily routine, including delays in being transferred to and from bed, which sometimes resulted in not being up at his preferred time. Resident B experienced missed activities, specifically being unable to attend scheduled smoking times on multiple occasions due to the unavailability of a Hoyer lift. Staff interviews confirmed that these delays were common and directly related to the insufficient number of mechanical lifts. Facility policies required accommodation of resident needs and preferences to the extent possible, but the lack of adequate equipment led to unmet care plans and resident dissatisfaction.
Failure to Monitor Resident Following DVT Diagnosis
Penalty
Summary
The facility failed to assess and monitor a resident for signs and symptoms of circulatory insufficiency in the right lower leg after the resident tested positive for deep vein thrombosis (DVT). The resident, who had a history of diabetes, end stage renal disease, and was on hemodialysis, was admitted with a diagnosis of DVT in the right popliteal vein. The care plan included interventions to monitor for swelling, pain, discoloration, and changes in the ability to move the lower extremity. However, there was no documentation that these assessments or monitoring were performed following the DVT diagnosis. Interviews with nursing staff and the DON confirmed that standard care and facility protocol required monitoring for pain, swelling, temperature changes, skin discoloration, and checking pedal pulses after a DVT diagnosis. Despite this, there was no evidence in the resident's records that such monitoring occurred. The lack of assessment and documentation was identified after the resident developed necrosis of the right foot, leading to hospital admission with a diagnosis of gangrene affecting multiple toes. The DON acknowledged the absence of a specific DVT management policy but stated that monitoring was an expected standard of practice.
Failure to Accurately Document Skin Changes and Wound Care
Penalty
Summary
The facility failed to ensure that a resident's medical records were accurate and complete in accordance with accepted professional standards and practices. Specifically, for one resident with a history of diabetes and fluctuating decision-making capacity, the nursing weekly summary and skin evaluations did not reflect significant skin changes that occurred over a ten-day period. Documentation showed that the resident was seen by wound care specialists who identified and reclassified a sacral pressure wound and noted new deep tissue injuries (DTIs) on the right heel and right lateral malleolus, with new treatment orders issued. However, there were no corresponding skin and wound evaluations or updated measurements recorded on the dates when these changes were identified, as required by facility protocol. Additionally, the nursing weekly summaries during this period consistently indicated that there were no new skin changes or breakdowns, despite the documented findings and new treatment orders from the wound care team. Interviews with the LVN and DON confirmed that skin evaluations and documentation should have been completed to reflect the changes in the resident's condition, including wound descriptions and measurements. The facility's own policy required that all changes in a resident's medical condition be documented in the clinical record, but this was not done, resulting in incomplete and inaccurate medical records for the resident.
Failure to Timely Report Alleged Physical Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of physical abuse within two hours to the California Department of Public Health (CDPH) as required by policy and regulation. On the evening of March 28, 2025, a resident (who is deaf and nonspeaking, with severe cognitive impairment) was allegedly struck on the back of the head by another resident with schizoaffective disorder and moderate cognitive impairment. The incident was witnessed by a third resident, who reported it to the nurse's station, where both an LVN and an RN were present. Documentation in the medical record confirmed the incident and subsequent monitoring of the resident, but there was no evidence that the required report to CDPH or the Ombudsman was made at that time. Interviews with staff revealed that the LVN informed the RN of the incident and relied on the RN for direction, but no further action was taken to report the abuse within the mandated timeframe. The RN assumed the LVN would handle the reporting, but did not follow up to ensure it was completed. The Director of Nursing was not informed of the incident until the following morning, well beyond the two-hour reporting window. Facility policy clearly states that all allegations of abuse must be reported to the appropriate authorities immediately, and within two hours if the incident involves abuse or results in serious bodily injury. The failure to report the alleged abuse in a timely manner was confirmed through record review, staff interviews, and review of facility policy. The delay in reporting had the potential to place the affected resident at continued risk of abuse and negatively impact her emotional and psychosocial well-being, as noted in the findings.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report a significant injury of unknown source for a resident, which involved a total right shoulder prosthesis dislocation. This incident was not reported to the California Department of Public Health (CDPH), police, or the Ombudsman within the required two-hour timeframe after the facility became aware of the injury. The resident, who had fluctuating capacity to make medical decisions, was admitted to the facility and later experienced pain and swelling in the right shoulder, leading to an X-ray that revealed the dislocation. Despite the facility's policy requiring immediate reporting of such injuries to rule out abuse, the incident was not reported as mandated. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the injury was of unknown source and should have been reported promptly to ensure resident safety and prevent further harm. The facility's policy on reporting injuries of unknown origin was not followed, as the injury was not communicated to the necessary authorities. This oversight had the potential to impact the resident's physical, emotional, and psychosocial well-being, as the injury could have been related to abuse.
Failure to Investigate Prosthesis Dislocation
Penalty
Summary
The facility failed to investigate the dislocation of a right shoulder prosthesis for a resident, which was identified as an injury of unknown source. The resident was admitted to the facility with no initial signs of limited range of motion, edema, or skin concerns. However, six days after admission, the resident complained of pain and swelling in the right shoulder, leading to an X-ray that revealed a dislodgement of the glenoid fossa portion of the prosthesis and a total shoulder dislocation. The resident was subsequently sent to the emergency room for further evaluation. Interviews with the Registered Nurse and the Director of Nursing revealed that the facility did not conduct an investigation into the cause of the prosthesis dislocation, despite the facility's policy requiring investigations for injuries of unknown origin to rule out possible abuse. The Director of Nursing acknowledged that the incident should have been investigated, as the facility was unaware of how the dislocation occurred, and there were no documented falls or injuries prior to the event. The facility's policy mandates that all reports of resident abuse, including injuries of unknown origin, be thoroughly investigated and reported to the appropriate agencies within five working days.
Failure to Provide Transfer Notice to Resident and Ombudsman
Penalty
Summary
The facility failed to provide a written copy of the transfer or discharge notice to a resident and their representative, as well as to the LTC Ombudsman, for a resident who was transferred to a hospital. The resident, who had fluctuating capacity to make medical decisions, was transferred due to a dislodgement and dislocation of a right shoulder prosthesis. Despite the facility's policy requiring that such notices be provided as soon as practicable, there was no documentation indicating that the resident received a written notice of the transfer or discharge. Additionally, the facility did not send a copy of the transfer or discharge notice to the LTC Ombudsman, which is required to ensure advocacy and oversight of the resident's discharge plan. The Director of Nursing and the Social Service Director acknowledged that the notice was not sent to the Ombudsman, as required by the facility's policy. The Social Service Director mistakenly believed that the hospital would send the notice, but admitted that it was his responsibility to ensure the Ombudsman was informed.
Failure to Provide Scheduled Showers and Bed Baths
Penalty
Summary
The facility failed to provide scheduled showers and bed baths for a resident, identified as Resident A, who was admitted with bilateral lower extremities contractures and a history of cerebrovascular accident with left-sided deficits. Resident A's care plan indicated a risk for decline in activities of daily living (ADLs) and required assistance due to hemiplegia, hemiparesis, muscle weakness, and atrophy. Despite this, documentation revealed that on several scheduled shower days in July and August 2024, Resident A received bed baths instead of showers, and on one occasion, neither a shower nor a bed bath was provided. There was no documentation indicating that Resident A refused showers on these days. Interviews with facility staff, including CNAs and an LVN, confirmed that Resident A was dependent on assistance for all ADLs and preferred bed baths. The Director of Nursing (DON) acknowledged that Resident A had a scheduled shower routine and that refusals should be documented and included in the care plan. However, the DON admitted that there were instances when Resident A was not provided with either a shower or a bed bath, contrary to the facility's protocol. This lack of adherence to the care plan and documentation requirements led to the deficiency identified in the report.
Failure to Reposition Resident Leads to Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident A, was repositioned and turned every two hours, which resulted in the development of a pressure ulcer. Resident A was admitted with diagnoses including hemiplegia and hemiparesis on the left side of the body, and was assessed as being at high risk for pressure ulcers according to the Braden Scale. The resident was completely immobile and required moderate to maximum assistance for movement. Despite these needs, the facility did not maintain a log or documentation to confirm that Resident A was repositioned as required. Interviews with facility staff, including a CNA and the Treatment Nurse, revealed that there was no documentation or schedule in place to track when Resident A was last turned. The Director of Nursing acknowledged gaps in the documentation and stated that if repositioning was not documented, it was assumed not to have been done. The facility's policy required repositioning every two hours for residents at risk of pressure ulcers, but this was not adhered to, leading to the progression of Resident A's pressure ulcer from Stage I to Stage II.
Failure to Timely Report Financial Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of misappropriation of property, a form of financial abuse, to the California Department of Public Health (CDPH) within the required two-hour timeframe. This incident involved a resident who reported missing finances, including a bank card and approximately $600, to a Social Service Assistant (SSA) on October 9, 2024, at around 2 p.m. The SSA did not report the incident to CDPH until October 10, 2024, at 3:16 p.m., which was 25 hours after the facility was made aware of the allegation. Both the SSA and the Director of Nursing (DON) acknowledged that the incident should have been reported within two hours to ensure the resident's safety and prevent further abuse. The facility's policy, titled 'Abuse Prevention,' mandates that all employees are required to report any allegations of abuse, including misappropriation of resident property, within two hours, even if there is no reasonable suspicion. The DON confirmed that all staff are mandated reporters and that any type of abuse, including financial abuse, should be reported promptly to CDPH, the ombudsman, and the police. The failure to adhere to this policy resulted in a delay in reporting the financial abuse allegation, potentially affecting the resident's emotional and psychosocial well-being.
Failure to Monitor Resident After Financial Abuse Allegation
Penalty
Summary
The facility failed to monitor a resident after an allegation of financial abuse, which had the potential to affect the resident's emotional and psychosocial wellbeing. The incident was reported on October 9, 2024, when the resident informed the social services that a family member had taken their wallet, resulting in missing cash and cards. A police report was filed, but the resident was not assessed or monitored for any negative psychosocial effects following the allegation. Interviews with the Social Service Director and the Director of Nursing revealed that the facility's standard practice was to monitor residents for 72 hours after any abuse allegations to assess for emotional distress and changes in behavior. However, this practice was not followed for the resident in question, and there was no specific policy in place to ensure such monitoring. The facility's existing policy on abuse prevention did not explicitly address the need for a 72-hour monitoring period, leading to a lapse in care for the resident involved in the financial abuse allegation.
Infection Control Deficiency Due to Inadequate Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented, as observed during a survey. A Physical Therapy Assistant (PTA) was seen not performing hand hygiene upon exiting and entering the rooms of two residents who were under Droplet Precaution, a type of transmission-based precaution (TBP). The PTA acknowledged the requirement to wash hands before entering and upon exiting these rooms to prevent the spread of pathogens and infections but admitted to not doing so. The facility's signage and policy on Droplet Precaution and Handwashing/Hand Hygiene clearly indicated the necessity of hand hygiene as a primary method to prevent the spread of infections. The Infection Preventionist (IP) confirmed that staff should perform hand hygiene when entering and exiting a resident's room, emphasizing its importance in preventing the spread of infection and disease. The failure of the PTA to adhere to these protocols was identified as a deficiency in the facility's infection control practices.
Failure to Notify Family of Grievance Investigation Results
Penalty
Summary
The facility failed to notify a resident's family member of the findings and results of a grievance investigation. The family member had filed a complaint regarding the resident being left unattended in a shower with cold running water. Despite the complaint being received and acknowledged by the facility, there was no documented evidence that the family member was informed of the investigation's outcome. The resident, who had severe cognitive impairment, was unable to advocate for themselves, making the family member's involvement crucial. Interviews with facility staff, including the Director of Nursing (DON) and the Quality Assurance Nurse (QAN), revealed that the investigation was conducted but not documented on a grievance form, nor were the findings communicated to the family member. The facility's grievance policy requires that grievances be investigated and the findings communicated to the complainant within five working days, which was not adhered to in this case. This oversight could lead to ongoing dissatisfaction from the family member, as they were left unaware of whether the complaint was addressed.
Incomplete Discharge Notice for Resident
Penalty
Summary
The facility failed to provide a complete written notice of transfer or discharge for a resident, which is a requirement for ensuring residents are informed about their future living arrangements. The deficiency was identified when a resident, who had been issued a discharge notice, stated that he could not read the notice due to poor eyesight and was unaware of his discharge location. The resident's record indicated that he was advised by the Ombudsman and CDP not to sign the notice but to appeal it instead. The Notice of Proposed Transfer/Discharge was found to be incomplete, lacking both the effective date of transfer/discharge and the discharge location. Interviews with the Director of Nursing (DON) and the Social Service Director (SSD) revealed that the SSD had provided the incomplete notice to the resident. The SSD admitted to leaving the discharge date and location blank because the resident had not yet decided on his next living arrangement, whether it would be a board and care or assisted living. The facility's policy requires that the discharge location be documented, but this was not adhered to in this case, leading to the deficiency.
Failure to Follow-Up on Ophthalmology Consult
Penalty
Summary
The facility failed to ensure a follow-up ophthalmology consult was provided for a resident, which increased the risk of the resident not receiving necessary care for their medical condition. The resident, who was admitted with diagnoses including Type II Diabetes Mellitus and Essential Hypertension, expressed the need to see an ophthalmologist, but reported that the facility had not taken any action. The resident's records indicated a need for an eye health and vision consult with follow-up treatment, as documented in the Order Summary Report and Care Plan. However, there was no documentation of a follow-up by the Social Service Director (SSD) for a consult with an optometrist or ophthalmologist from February to August 2024. Interviews with the Director of Nursing (DON) and the SSD revealed that the SSD did not make a follow-up on the resident's consult with the optometrist or ophthalmologist. The DON stated that the SSD should have ensured the follow-up and scheduled the appointment if the resident needed to be seen by an ophthalmologist. The facility's job description for the SSD emphasized the responsibility to assist residents in achieving the highest practicable level of self-care and well-being, which includes providing medically related social services.
Narcotic Medication Documentation Deficiency
Penalty
Summary
The facility failed to maintain proper accountability for narcotic pain medications for 20 residents, leading to potential medication discrepancies and possible diversion of controlled substances. The report highlights multiple instances where licensed nurses signed out narcotic medications from the medication count sheet but failed to document their administration in the electronic Medication Administration Record (eMAR). This lack of documentation was observed across various residents, including those with conditions such as muscle wasting, chronic pain, and severe pain management needs. For example, Resident 58, who was admitted with diagnoses including muscle wasting and polyneuropathy, had several doses of Oxycodone-Acetaminophen signed out by nurses without corresponding documentation in the eMAR. Similarly, Resident 65, with necrotizing fasciitis and polyneuropathy, had multiple instances where Oxycodone-Acetaminophen was signed out but not documented as administered. These discrepancies were confirmed through interviews with the involved Licensed Vocational Nurses (LVNs), who acknowledged the failure to document the administration of these medications. The report further details similar issues with other residents, such as Resident 19, whose hydrocodone/acetaminophen doses were inconsistently documented, and Resident 83, who had numerous doses of hydrocodone-acetaminophen signed out without eMAR documentation. The facility's process for administering PRN narcotic pain medications requires nurses to sign out the medication, administer it, and document the administration in the eMAR. However, this process was not consistently followed, leading to significant gaps in medication administration records and raising concerns about potential medication errors and resident safety.
Facility Lacks Qualified Social Worker for 132-Bed Capacity
Penalty
Summary
The facility, which has a licensed capacity of 132 beds, failed to employ a full-time qualified social worker, as required for facilities with more than 120 beds. During an interview and record review, it was revealed that the Social Service Director (SSD) had been employed for over a year but did not possess a bachelor's degree in social work or a related human services field, nor was she a licensed medical social worker. Furthermore, the SSD was not supervised by a qualified social worker, which is a requirement for her role. The SSD admitted to not being qualified to perform psychosocial assessments, which could potentially lead to physical and psychosocial distress among residents. The facility's job description for social service staff, dated March 2017, clearly stated the requirement for a bachelor's degree in social work or human services. Additionally, the facility's policy and procedure document from October 2010 specified that the Director of Social Services should be a qualified social worker to provide medically related social services, ensuring residents attain or maintain their highest practicable physical, mental, or psychosocial well-being. The Administrator confirmed that the SSD was not qualified to fulfill the responsibilities of a social worker for the facility, highlighting a significant deficiency in meeting the required standards for resident care.
Failure in Narcotic Accountability and Pain Assessment
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively identified and addressed issues related to narcotic medication accountability and pain assessment. During QAPI meetings held in February and April 2024, concerns were raised about narcotic medications being signed out by Licensed Nurses (LNs) on the narcotic count sheet but not documented as administered in the Electronic Medication Administration Record (e-MAR). Additionally, it was noted that pain assessments, monitoring, and evaluations were not being conducted by LNs after administering pain medication. Despite these issues being identified, the facility did not monitor or re-evaluate the effectiveness of the interventions implemented to address them. The Director of Nursing (DON) acknowledged that the facility should have re-evaluated and monitored these interventions to ensure the safety and accountability of narcotic medications and to manage residents' pain effectively. This oversight had the potential to lead to the diversion of controlled medications and unrelieved pain among residents, which could compromise their overall health and wellbeing.
Delayed Call Light Response and Meal Service Issues
Penalty
Summary
The facility failed to ensure the residents' rights were promoted and respected, as evidenced by the delayed response to call lights for several residents. Residents 23, 29, 59, 106, and 126 reported that their call lights were not answered promptly, leading to potential risks of not receiving timely care. During interviews, these residents expressed concerns about waiting times ranging from 10 to 30 minutes for assistance after activating their call lights. The issue was previously discussed in Resident Council meetings but remained unresolved. Staff interviews confirmed the expectation for prompt response to call lights, yet the facility's policy was not adhered to, as evidenced by the residents' experiences. Additionally, the facility failed to serve meals simultaneously to residents dining together, impacting Resident 112's dignity and meal intake. Resident 112 observed that Resident 41 consistently received her meal first, causing Resident 112 to feel upset and left out. The Registered Dietitian acknowledged that both residents should have received their meals at the same time, and the facility's policy emphasized treating residents with dignity and respect. This oversight in meal service had the potential to affect Resident 112's enjoyment and intake of her meals.
Failure to Conduct Self-Administration Assessments for Medications
Penalty
Summary
The facility failed to conduct assessments for the safe self-administration of medication for three residents. One resident had a pink medication pill left on their overbed table by a nurse, which the resident did not take because they were sleepy. This resident had no documented self-administration assessment in their medical record. Another resident had an opened bottle of eyedrops on their overbed table, which they used to relieve irritation and itchiness, but there was no physician's order or self-administration assessment documented. A third resident had an opened bottle of dietary supplements on their overbed table, which they took daily with the staff's awareness, yet there was no physician's order or self-administration assessment documented. The Licensed Vocational Nurses (LVNs) involved acknowledged the lack of assessments and physician orders for the medications and supplements found at the residents' bedsides. The Director of Nursing (DON) stated that the facility's policy and procedure require medications to be administered according to physician orders and that self-administration assessments should be conducted to ensure safety. The facility's policy also specifies that medications should not be left with residents unless they have been approved for self-administration, and any unauthorized medications found at the bedside should be turned over to the nurse in charge.
Failure to Provide Advance Directive Education
Penalty
Summary
The facility failed to provide education and resources for Advance Directives (AD) to 15 out of 25 residents, as well as their Resident Representatives (RP). This deficiency was identified through interviews and record reviews, revealing that residents and their representatives were not informed about ADs, which are crucial for understanding and documenting a resident's wishes regarding medical treatment. The lack of documentation and education was evident in the medical records of the affected residents. Several residents, including those with dementia and Alzheimer's disease, were found to have no documented evidence of receiving information or education about ADs. For instance, Resident 15, who was diagnosed with dementia, did not have the capacity to make decisions, yet there was no record of AD education provided to the resident or their RP. Similarly, Resident 60, who had the capacity to make decisions, also lacked documentation of AD education, despite the resident's ability to understand and make informed choices. The Social Service Director (SSD) acknowledged during interviews that she did not provide the necessary AD education or follow-up to the residents and their representatives. This oversight was consistent across multiple cases, where residents either had the capacity to make decisions or were unable to do so due to cognitive impairments. The facility's policy required that residents be provided with written information about their right to formulate an AD upon admission, but this was not adhered to, leading to the deficiency.
Failure in Pain Management Documentation and Assessment
Penalty
Summary
The facility failed to ensure proper pain management for 20 residents who required such services. The deficiency was identified through observations, interviews, and record reviews, revealing that licensed nurses did not conduct pain assessments prior to administering PRN narcotic pain medications, nor did they evaluate the effectiveness of the medications after administration. This lack of documentation and assessment was consistent across multiple residents, including those with conditions such as osteomyelitis, diverticulosis, muscle wasting, atrophy, polyneuropathy, necrotizing fasciitis, and chronic pain syndrome. For instance, Resident 18, who was admitted with osteomyelitis and diverticulosis, had multiple doses of Tramadol administered without prior pain assessment or post-administration evaluation. Similarly, Resident 58, diagnosed with muscle wasting and polyneuropathy, received oxycodone-acetaminophen without documented pain assessments or evaluations of the medication's effectiveness. Interviews with licensed vocational nurses confirmed the absence of necessary documentation and assessments, acknowledging the failure to follow the facility's pain management protocols. The deficiency extended to other residents, such as Resident 65 with necrotizing fasciitis, Resident 19 with knee pain, and Resident 278 with idiopathic neuropathy, all of whom received narcotic pain medications without proper assessments. The lack of documentation and evaluation potentially compromised the residents' pain management, as the facility's process for administering PRN narcotic pain medications was not adhered to, placing residents at risk of experiencing unrelieved and unmanaged pain.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that Food and Nutrition Service employees were able to carry out their functions safely and effectively, leading to several deficiencies. Firstly, multiple employees were observed not following the proper cleaning procedures for kitchen equipment. Specifically, Diet Aide 1 and Cook 1, among others, were using only sanitizer instead of first cleaning with detergent and then sanitizing, as per the facility's policy. This improper cleaning method was acknowledged by the Registered Dietitian and Dietary Service Supervisor, who confirmed that the correct procedure involves removing debris, washing with detergent, rinsing with water, and then sanitizing. Secondly, there was a lack of knowledge regarding the correct concentration of chlorine for the dish machine among the staff. Diet Aides 3 and 4 were observed checking the chlorine levels incorrectly, believing it should be 200 ppm, while the Dietary Service Supervisor clarified that the correct range is 50-100 ppm. This misunderstanding could lead to a strong chloride odor being transferred to clean kitchenware, as the concentration was too high. Lastly, Cook 1 did not follow the recipe for making pureed Bread Stuffing, resulting in overly salty servings for eight residents on a pureed diet. Instead of using milk as specified in the recipe, chicken broth was used, which combined with the bread stuffing, led to a high salt content. The Registered Dietitian confirmed that the failure to follow the recipe and sample the food before serving contributed to the issue.
Deficiency in Meal Service Temperature and Palatability
Penalty
Summary
The facility failed to adhere to its MEAL SERVICE policy, resulting in the provision of unappetizing food at inappropriate temperatures for nine residents. Observations and interviews revealed that residents consistently received cold meals, bland and tough meat, and vegetables that appeared old and reheated. Additionally, milk was served warm, and pureed meals were excessively salty due to improper recipe adjustments. These issues were confirmed through resident interviews and a test meal evaluation conducted with the Registered Dietitian (RD) and Dietary Services Supervisor (DSS). The test meal evaluation showed that food temperatures did not meet the facility's policy standards, with cold items being served warmer than recommended and hot items cooler than required. The RD acknowledged that the meal service process was inefficient, with meal carts left open during delivery, contributing to temperature discrepancies. The facility's policy specified that cold desserts should be served at 50 degrees Fahrenheit or less, milk and cold beverages at 45 degrees Fahrenheit or less, and vegetables at 120 degrees Fahrenheit or more, but these standards were not met during the survey.
Unsanitary Food Preparation and Storage Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices in the kitchen, as evidenced by multiple observations of unsanitary conditions. Mold, dust, and hair were found in the walk-in refrigerator, with the Dietary Service Supervisor (DSS) confirming the presence of these contaminants. The Registered Dietitian (RD) verified the mold and dust, acknowledging that no staff member was assigned to clean the storage shelves in the refrigerator. Additionally, calcium buildup was observed on the hot water spout, which the RD stated could contaminate the hot water. Further observations revealed that wet plastic containers were improperly stacked with dry ones, which the DSS and RD agreed could promote microbial growth. Dust was also found on various kitchen equipment, including fans and shelves, which the DSS confirmed could contaminate food and clean dishes. Rust was observed on several pieces of equipment, such as storage shelves and a can opener base, with the RD stating that rust should not be present as it could cause cross-contamination. Chipped paint was noted on kitchen equipment, including a mixer and utensil hanger, which the RD indicated needed repair or replacement to prevent contamination. An unsanitary microwave was found in a pantry room, with black and brown particles inside, which the RN confirmed was an infection control issue. The facility's policies and procedures emphasized the importance of keeping equipment clean and free from corrosion, yet these standards were not met, posing a risk of foodborne illness to the residents.
Failure to Maintain Homelike Environment Due to Noise Disturbance
Penalty
Summary
The facility failed to provide a homelike environment for a resident, identified as Resident 107, who complained about uncomfortable noise levels during sleeping hours. Resident 107, who was admitted with a diagnosis of hypotension, reported being disturbed by noise from another resident gardening early in the morning. This issue was documented in the resident's care plan and health status notes, indicating repeated complaints about the noise disrupting sleep. During an interview, the resident expressed being woken up early due to banging noises outside. A Licensed Vocational Nurse (LVN) confirmed that Resident 107 had made multiple complaints about the noise, emphasizing the need for a quiet and comfortable environment to promote rest. The Director of Nursing (DON) acknowledged the expectation for staff to maintain acceptable noise levels during sleeping hours, in line with the facility's policy on providing a homelike environment. The facility's policy, dated May 2017, highlighted the importance of person-centered care and maintaining comfortable noise levels.
Failure to Conduct Accurate Smoking Assessment for Resident
Penalty
Summary
The facility failed to conduct an accurate smoking assessment for a resident who uses electronic cigarettes. The resident, who was admitted with a diagnosis of pulmonary hypertension and was assessed as cognitively intact, was not properly evaluated for smoking habits. Despite the resident's admission record indicating no use of tobacco products, the resident admitted to smoking occasionally when stressed and was observed smoking in a non-designated area. Staff, including an LVN, were aware of the resident's smoking habits, as evidenced by the smell of smoke on the resident after gardening. The Activity Director, responsible for conducting smoking assessments, did not update the resident's smoking status despite being informed of the resident's smoking behavior. The facility's smoking policy, which includes guidelines for the use of electronic cigarettes, was not adhered to, as the resident was not assessed for safe handling of the device, nor was the use documented in the resident's care plan. This oversight had the potential to result in injury to the resident due to the risks associated with electronic cigarette use.
Failure to Adhere to Oxygen Therapy Order
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 52, by not adhering to the physician's order for oxygen therapy. Resident 52 was admitted with diagnoses involving the circulatory and respiratory systems and had a care plan indicating a potential for shortness of breath, with an intervention of oxygen at 2 liters per minute (LPM) via nasal cannula. However, during an observation and interview, it was found that Resident 52 was receiving oxygen at a flow rate of 4 LPM, which was not in accordance with the physician's order. Licensed Vocational Nurse (LVN) 1 confirmed that the oxygen flow rate was set incorrectly at 4 LPM instead of the prescribed 2 LPM. Registered Nurse (RN) 1 also acknowledged that the resident should have been receiving oxygen at the correct flow rate of 2 LPM, and that the increased flow rate had the potential to cause oxygen toxicity. The facility's policy on oxygen administration, dated October 2010, requires verification of the physician's order to ensure safe oxygen administration, which was not followed in this instance.
Failure in Dialysis Care and Fluid Management
Penalty
Summary
The facility failed to provide appropriate post-dialysis care for Resident 100, who was diagnosed with end-stage renal disease and required hemodialysis. On August 17, 2024, Resident 100 returned from a dialysis appointment, but there was no documented post-dialysis assessment conducted by a licensed nurse, as required by the facility's policy. Both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the assessment was not performed, which was necessary to monitor for potential dialysis complications. For Resident 23, the facility did not adhere to the physician's recommendation to discontinue fluid restriction, nor did it consistently monitor the resident's intake and output (I&O). Despite a physician's order dated June 21, 2024, to discontinue the fluid restriction, staff continued to restrict fluids, as indicated by the green dot sticker on the resident's door and the absence of a water pitcher at the bedside. The facility's records showed incomplete documentation of I&O monitoring, which was crucial for managing the resident's condition, given the diagnosis of end-stage renal disease and dependence on dialysis. Interviews with various staff members, including LVNs and CNAs, revealed a lack of communication and understanding regarding Resident 23's fluid management plan. The staff was unaware of the updated physician's orders and failed to document fluid intake accurately, as required by the facility's policy. This oversight in monitoring and documentation could lead to complications related to fluid imbalance, such as fluid overload or dehydration, for Resident 23.
Failure to Monitor Behavior for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to conduct behavior monitoring for a resident receiving Olanzapine, a medication used to treat schizophrenia. The resident, who was admitted with a diagnosis of schizophrenia, had a physician order for Olanzapine to manage auditory hallucinations. However, there was no documentation of behavior monitoring for these hallucinations in the resident's medical record. This lack of monitoring was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a care plan addressing the resident's auditory hallucination behavior. The facility's policies on psychotropic medication use and care planning emphasize the importance of monitoring the effectiveness of medications and assessing for adverse consequences. Despite these policies, the resident's behavior was not monitored, and a care plan was not developed upon admission. The MDS coordinator also confirmed that licensed nurses should have been monitoring the resident's behavior to provide a basis for gradual dose reduction and potential medication adjustment by the doctor.
Improper Storage of Discontinued Medications
Penalty
Summary
The facility failed to ensure that discontinued medications were stored properly and not readily available for use. During an observation in the Westside medication room, two vials of Lorazepam and an Insulin Lispro Injection pen, both marked as discontinued, were found in the medication room refrigerator. The Registered Nurse (RN) present stated that the facility's process for discontinued medication is to either give it to the resident at discharge or destroy it, and acknowledged that the medications should not have been left in the refrigerator. The RN was unsure why the medications were still there and mentioned that the night shift nurses should have discarded them. The Director of Nursing (DON) confirmed that discontinued medications should not be kept in the refrigerator and should be placed in a designated discontinue bin. The DON also stated that narcotic medications require destruction with two nurse signatures and that she, along with the pharmacist consultant, destroys medications once a month. The facility's policies indicate that discontinued or outdated drugs should be stored in a secured area until picked up by the pharmaceutical disposal service or pharmacy personnel, and that the facility shall not use discontinued, expired, or deteriorated drugs.
Failure to Implement Therapeutic Diet and Fortification for a Resident
Penalty
Summary
The facility failed to implement the therapeutic diet order prescribed by the attending physician for Resident 23, who was diagnosed with End-Stage Renal Disease and was on hemodialysis. Despite the physician's order specifying a No Added Salt (NAS) diet with certain food preferences and restrictions, the dietary department did not adhere to these instructions. Observations revealed that Resident 23 was served meals that included items he disliked, such as rice, which was explicitly mentioned in his dietary preferences as something to avoid. This inconsistency between the physician's diet order and the meals provided to Resident 23 was confirmed by the Registered Dietician (RD), who noted that the dietary department was not following the prescribed diet order. Additionally, the RD had recommended fortifying Resident 23's diet due to his poor appetite and weight loss, which was documented in the progress notes. However, there was no evidence that this recommendation was communicated to the physician or implemented. The RD stated that after making such a recommendation, the nursing staff should have followed up with the physician and the Director of Nursing (DON) to ensure the diet was fortified. The lack of follow-up on the RD's recommendation meant that Resident 23's diet was not adjusted to provide the extra nutrients he needed. The facility's policy on therapeutic diets, which requires that diet orders match the terminology used by the food and nutrition services department and be determined in accordance with the resident's preferences and treatment goals, was not adhered to in this case. The failure to implement the physician's diet order and the RD's recommendation for fortification had the potential to impact Resident 23's nutritional status and overall health.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in two observed instances. In the first instance, a Certified Nursing Assistant (CNA) did not clean and disinfect a Hoyer lift before and after using it to transfer a resident. The CNA acknowledged the oversight and admitted that the lift should have been cleaned to prevent the spread of infection. The resident involved was on enhanced barrier precautions due to an Extended Spectrum Beta Lactamase (ESBL) infection, which requires specific measures to prevent transmission. In the second instance, a Registered Nurse (RN) did not wear personal protective equipment (PPE) while administering intravenous medication and changing the dressing of a resident with an ESBL infection. The RN admitted to not wearing PPE and acknowledged the necessity of doing so to prevent the spread of pathogens. The Infection Preventionist Nurse and the Director of Nursing confirmed that the staff should have followed the facility's infection control policy, which mandates the use of PPE and disinfection of equipment to prevent infection transmission.
Pest Control Deficiency Due to House Flies
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of house flies in the kitchen and East activity room. On August 19, 2024, a house fly was observed landing on a cleaned plastic container in the kitchen's prep juice area during an observation and interview with the Dietary Service Supervisor (DSS). The DSS indicated that the delivery man had propped the door open, allowing the fly to enter. On August 20, 2024, another house fly was seen landing on a resident's served food in the East activity room during an observation and interview with Certified Nurse Assistant (CNA) 3. CNA 3 noted that the fly entered when residents opened the door to go outside to smoke. An interview with the Registered Dietitian (RD) on August 21, 2024, confirmed that house flies carry bacteria that could contaminate food, emphasizing that the facility should be free of pests. A review of the facility's Policy and Procedure (P&P) on pest control, revised in May 2008, stated that the facility should maintain an ongoing pest control program to keep the building free of insects. Additionally, the P&P on miscellaneous areas, dated 2023, highlighted that flies are carriers of disease and pose a threat to sanitation standards in the Food & Nutrition Services Department.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
The facility failed to adhere to its hand hygiene policy during wound care for a resident, leading to a potential risk of contamination. During an unannounced visit, a Treatment Nurse (TN) was observed providing wound care to a resident with a sacral wound. After removing her gloves, the TN did not perform hand hygiene before donning a new pair of gloves, which is against the facility's policy. This lapse occurred while the TN was handling wound care materials, including gauze and wound cleanser, for the resident's sacral wound. The resident involved had a complex medical history, including sepsis, osteomyelitis, hemiplegia, and a stage 4 pressure ulcer in the sacral region. The facility's policy requires hand hygiene to be performed after removing gloves and before putting on a new pair, which the TN acknowledged she failed to do. The Infection Preventionist confirmed that the staff should follow this protocol during wound care. The resident's medical records indicated ongoing treatment for the sacral pressure injury, which required careful handling to prevent infection.
Lack of Dedicated Dietary Manager Leads to Food Safety Oversight Issues
Penalty
Summary
The facility failed to employ a dedicated Dietary Manager (DM) to oversee the food and nutrition services, which led to a lack of oversight in food safety practices. During an unannounced visit, it was observed that the facility did not have a dedicated DM, and the duties were being shared among a Dietary Corporate Consultant (DCC), a Registered Dietitian (RD), and a DM from a sister facility. This arrangement resulted in lapses in food safety practices, such as missing use-by dates on food items in the refrigerator, including Italian dressing and egg salad. Interviews with staff revealed that the absence of a dedicated DM negatively impacted their work, as they experienced issues like running out of supplies. The DCC admitted that checking expiration dates was the DM's responsibility, but due to the lack of a dedicated DM, this task was not consistently performed. The Administrator confirmed the absence of a dedicated DM, highlighting the facility's failure to ensure proper staffing for food and nutrition services.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to ensure that food items were stored in accordance with professional standards for food service safety. During an observation and interview on July 18, 2024, it was noted that certain food items in the refrigerator, such as Italian dressing and egg salad, were missing use-by or expiration dates. The Dietary Care Coordinator (DCC) acknowledged that all food items should have received, open, and use-by dates, and confirmed that the egg salad prepared that morning was missing an expiration date. The dietary staff member responsible for preparing the egg salad admitted to forgetting to label the container with an expiration date. Further interviews revealed that it was the responsibility of the Dietary Manager (DM) to check expiration dates on all foods in the kitchen, including those in the refrigerator. However, this task was not completed because there was no DM present at the time. The DCC, who had just started her shift, had not yet had the opportunity to check the expiration dates. The facility's policy and procedure on labeling and dating foods, dated 2023, clearly indicated that all food items in storage areas need to be labeled and dated, but this was not adhered to, leading to the deficiency.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to ascertain the current condition of a resident prior to refusing the resident's re-admission after hospitalization. The resident, who had been living at the facility for several years, was transferred to the emergency room for psychiatric evaluation and treatment following a major behavioral outburst. Despite the resident's long-term stay and the absence of a bed-hold policy, the facility did not follow up with the hospital to determine if the resident's behavior had stabilized before deciding not to readmit him. The decision was made based on the resident's previous behavior and a psychologist's note indicating that the resident was a danger to himself and others. Interviews with facility staff, including the Medical Records Director, Licensed Vocational Nurse, Director of Nursing, and Administrator, revealed that the decision not to readmit the resident was made without proper assessment of his current condition. The Director of Nursing admitted to not following up with the hospital regarding the resident's behavior improvement. The Administrator stated that the decision was made in the best interest of other residents and employees. The facility's policy on bed-holds and returns, which requires residents to be permitted to return following hospitalization, was not adhered to in this case.
Failure to Provide Bed Hold Information and Notice of Proposed Transfer/Discharge
Penalty
Summary
The facility failed to ensure that information related to bed hold policies was provided to the family member of a resident who was transferred to a hospital for psychiatric evaluation and treatment. The resident, who had a history of traumatic brain injury and adjustment disorder, was transferred under a 51-50 code due to aggressive behavior. The facility did not provide a bed hold for the resident, and the Notice of Proposed Transfer/Discharge (NOPTD) was not given to the resident or the responsible party within the required 24-hour period. Interviews with the Social Service Director (SSD) and the Director of Nursing (DON) revealed that the decision to not provide a bed hold was made as a team due to the resident's increasingly difficult behavior. The DON also admitted to not following up with the hospital to check if the resident's behavior had stabilized. The facility's policy requires that all residents or their representatives be provided with written information about bed hold policies at least twice, well in advance of any transfer and at the time of transfer, or within 24 hours in case of an emergency transfer. This policy was not followed in this case.
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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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