Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Ellison John Transitional Care Center during CMS and state inspections, most recent first.
Failure to continue and reassess wound care for a resident with a right craniotomy incision led to worsening drainage, dehiscence, and purulent drainage from the ear and incision. The resident had severe neurologic impairment and dependence for care, and wound records showed progression from a dry scab to swelling, clear fluid leakage, then purulent drainage. Treatment records showed missed or incomplete wound care documentation, and staff stated they did not verify whether the wound orders should continue. The resident was later found with maggots in the ear canal and at the surgical site and was transferred for hospital evaluation.
Unnecessary Psychotropic Medication Use Without Documented GDR Rationale: A resident with depression remained on Zoloft 50 mg daily even though MDS assessments showed no depressive symptoms and the MAR reflected almost no documented behaviors. The DON acknowledged the resident’s care plan goals had been met, but the psych note did not provide a specific clinical rationale for continuing the antidepressant at the original dose or a documented contraindication to GDR, despite facility policy requiring GDR attempts or clear clinical justification.
Indwelling Catheter Care and Monitoring Failures: A resident with a catheter had repeated leakage, no documented urine output on multiple shifts, and no SBAR notification when the catheter was bypassing and staff could not change it; the resident later required hospital transfer for urinary retention and abdominal discomfort. A second resident’s catheter tubing was observed in a dependent loop with stagnant urine and positioned above the bladder, contrary to the facility’s stated catheter care practices for maintaining drainage and preventing UTI.
Controlled substance reconciliation and documentation were not completed correctly. Two refrigerated eKITs containing lorazepam were not counted and reconciled at each shift change, and a nurse did not accurately document controlled substance doses for two residents on the accountability record. One resident’s pregabalin count was off by one tablet, and another resident’s lacosamide count was off by one tablet, with the nurse acknowledging that one dose was signed before administration and another was administered without timely documentation.
A resident with DM2 received two doses of expired Novolog FlexPen after staff left an opened pen in the med cart past its beyond-use date, and two different LVNs documented giving it. Another resident with ESRD and A-fib was given amiodarone despite an order to hold it when SBP was below 110, and the MAR showed it was administered when the resident’s SBP was 102 and 108. The DON and nursing staff confirmed the medication administration errors.
Expired and unlabeled meds were found in several med storage areas. An open Epogen vial for a resident lacked an opening date, an insulin Lispro pen and an insulin Novolog pen were kept past their discard dates, and two opened pouches for a resident’s levalbuterol and dorzolamide/timolol were not labeled with opening dates. RN and LVN staff acknowledged the products were expired or improperly labeled, and the DON confirmed that multi-dose meds must be dated when opened and expired meds removed from active stock.
Call lights were not kept within reach for two residents at risk for falls. One resident had severe cognitive impairment, generalized weakness, and needed significant help with mobility and ADLs; the other had cervical spinal stenosis, generalized weakness, and a history of falling. In both rooms, a CNA observed the call light positioned between the side rail and mattress, and the CNA, LVN, and DON stated the residents would not have been able to call for assistance and that the Resident Call System policy and care plans were not followed.
A resident with an indwelling catheter had bypassing and zero urine output in the drainage bag for an entire day shift, but staff did not immediately notify the physician using SBAR. The resident, family, and CNA reported the catheter had been leaking for days, while an LVN said she was unaware of the issue. The MDS nurse and DON stated the bypassing/no-output situation was a change in condition that required physician notification, and the resident later developed abdominal distention and urinary retention requiring hospital transfer.
Unsafe Room Conditions and Obstructed Floor Mat: Two residents with significant fall risk factors were found in unsafe environments. One resident with dementia, epilepsy, weakness, and a recent fall with major injuries was observed unattended while a puddle of clear liquid remained on the floor despite staff entering and leaving the room. Another resident with dementia, head contusion, dysphagia, weakness, alcohol dependence, and a history of falls had a chair and trash bin placed on top of the floor mat beside the bed, even though staff stated the mat should be kept clear to reduce injury from falls.
Incorrectly Labeled Enteral Flush Bag: A resident with a feeding tube and severe cognitive impairment had orders for tube feeding and water flushes via kangaroo pump, but the flush bag was observed hanging with clear liquid and labeled as Diabetisource instead of water. An LVN and the DON both stated the label was incorrect and confusing because the flush bag should have identified the correct solution name along with the rate, time, and date.
Unlabeled oxygen tubing was observed for two residents receiving NC oxygen. Both residents had respiratory diagnoses and were cognitively able to understand or make decisions. An LVN stated the tubing should be labeled with the start or change date for infection control and is changed weekly or as needed; without a label, staff would not know when it was last changed. The DON stated the missing date prevents staff from determining when the tubing is due for replacement and from monitoring timely tubing changes per the facility’s infection prevention practice.
A resident with DM2 was prescribed Regular insulin per sliding scale SQ every 6 hours, but the clinical record did not contain baseline or subsequent HgA1c results. The DON and CP stated that HgA1c monitoring was needed to evaluate insulin effectiveness and that blood sugar checks alone were not enough to assess the regimen.
A resident with cerebral infarction, diabetes, muscle weakness, significant memory loss, and total dependence for feeding missed a lunchtime meal when medical transport arrived for an appointment. Staff gave Ensure instead of a meal, while the RD, DD, and DON confirmed that Ensure is not a meal replacement and that a packed meal or sack lunch should have been arranged through the kitchen.
An LVN failed to follow EBP while administering medications to a resident with wounds. Although an EBP sign was posted and the resident was on EBP due to wounds, the LVN entered the room and gave 14 medications without gloves and a gown. The LVN acknowledged the error, and the DON confirmed the resident’s EBP status and that the LVN did not follow facility P&P for EBP and infection control.
Failure to Monitor Residents After COC After an alleged physical altercation between two residents, the facility did not document required shift-by-shift monitoring for one resident with metabolic encephalopathy, muscle weakness, and depression, whose MDS showed severely impaired decision-making, and for another resident with cerebral infarction, hemiplegia, and type 2 DM, whose MDS showed intact cognition. The ADON stated residents should be monitored every shift for 72 hours after a COC, but progress notes lacked documentation for multiple shifts for one resident and one shift for the other; care not documented was considered not provided.
Inaccurate MDS Skin Assessment: A resident with hemiplegia, hemiparesis, type 2 DM, and muscle weakness had an inaccurate skin assessment on the MDS. The admission evaluation did not show a DTI, but the MDS later documented one unstageable DTI as present on admission. The MDSN stated the DTI developed at the facility and confirmed the skin assessment was inaccurate; the DON acknowledged the MDS was not accurately documented and was used as part of the resident’s care plan.
Delayed Documentation of Resident Assessment: A resident with metabolic encephalopathy, muscle weakness, depression, and severely impaired cognitive skills had assessments after a change of condition documented late by an ADON. The ADON and DON stated the assessments were not entered timely and were not marked as late entries, despite the facility policy requiring timely late-entry documentation.
Care Plan Not Revised After G-Tube Dislodgement: A resident with a G-tube, bipolar disorder, and DM II had a change of condition when the tube became dislodged, with redness and drainage at the stoma site, and the resident was transferred to the GACH. The MDS Coordinator stated the care plan was not revised to reflect the G-tube issue, and the DON stated it should have been updated to address needed G-tube care and prevent accidents.
A resident with multiple medical conditions and fluctuating decision-making capacity developed new wandering behavior, repeatedly entering another resident’s room. Although another resident reported this to an LPN, no Change of Condition evaluation was completed, and there was no documentation that the MD or the resident’s representative were notified, contrary to facility policy. Required 72-hour, every-shift monitoring and SBAR documentation following this significant change in condition were not recorded on multiple shifts, resulting in undocumented assessment and monitoring of the resident’s new wandering behavior.
A resident with diabetes, glaucoma, generalized weakness, and intact cognition required maximum assistance with ADLs per the MDS, but the ADL care plan only stated that assistance with eating was needed and did not specify the type or level of help, despite the resident’s visual impairment and documented need for maximum assistance. Family reported that staff delivered meal trays, briefly described the contents, and left the resident to eat alone, with some items not actually present on the tray. The resident had PRN orders for bisacodyl and MOM for constipation, and bowel records showed several days without bowel movements, yet the MAR showed these medications were not administered as ordered, contrary to the constipation care plan intervention to give medications as ordered. The MAR also documented that the resident refused insulin glargine on two occasions, but no care plan was developed to address this treatment refusal, even though facility policy requires the comprehensive care plan to identify declined services, associated risks, and IDT efforts when a resident refuses treatment.
A resident with DM, HTN, and other conditions did not receive PRN bisacodyl suppositories or MOM despite documented days without bowel movements, and one bisacodyl dose that was given was not recorded on the MAR. The resident also had ordered daily glargine insulin that was not administered on days when blood glucose levels were above the hold parameter, and scheduled enoxaparin, metformin, and metoprolol were repeatedly given outside the facility’s required one-hour window around the scheduled times. Interviews with an LVN and the DON confirmed that these actions did not follow physician orders or facility medication administration policies.
Two residents who were frequently incontinent and required maximum assistance for ADLs reported delayed responses to their call lights, including one episode where a resident experiencing vomiting waited 30–60 minutes without staff response and another who often had to involve a family member when evening-shift staff did not respond promptly for incontinent care. The DON acknowledged that delayed call light response can delay meeting residents’ needs, and facility policy states that residents must be able to summon staff through the call system.
A resident with multiple medical conditions, including DM, generalized weakness, and glaucoma, experienced vomiting, prompting an RN to notify the resident’s POA, who requested COVID-19 testing. The RN performed the test, which was negative, but neither the SBAR nor progress notes contained documentation that the POA was informed of the result. In interviews, the POA reported not being told the outcome, and staff, including an LVN and the RN, acknowledged there was no record of notification, despite facility policy requiring documentation of communication with the resident representative.
A resident with a history of intracerebral hemorrhage, DM, and generalized weakness, who was cognitively intact but required maximum assistance with ADLs, had a COC form completed after a bisacodyl suppository was inserted into the frontal private area. The COC lacked documentation of the date of the last bowel movement to support the intervention, despite facility policy and SBAR charting instructions requiring complete documentation or use of N/A when information is not applicable. A family member reported the suppository was inserted in the wrong area, and staff acknowledged the COC was incomplete and did not provide adequate clinical justification in the medical record.
A resident with type 2 DM and severely impaired cognition had physician orders for blood glucose checks every four hours and for shift-by-shift monitoring and documentation of hypoglycemia signs and symptoms. Over a 21‑day period, the MAR and blood sugar summary showed glucose levels were recorded only four times daily instead of every four hours, with no evidence of the ordered monitoring. During a hypoglycemic change of condition with labored breathing, altered level of consciousness, and a documented blood sugar of 45 mg/dL, the resident’s hypoglycemia signs and symptoms were recorded on a COC form but not documented in the MAR. The LVN and DON acknowledged that the required monitoring and documentation were not completed as ordered and that undocumented care was considered not done, contrary to facility policies on diabetes management and clinical documentation.
A resident with type 2 DM and severely impaired cognition experienced hypoglycemia with labored breathing and altered consciousness, and staff administered glucagon 1 mg IM and glucose gel 40% during the event. The glucose gel had been previously discontinued and was given without a current physician order, while the glucagon administration, though ordered, was not documented on the MAR, only on the change-of-condition form. Interviews with an RN, an LVN, and the DON confirmed that the medication was given without an active order and that required MAR documentation for the glucagon dose was missing.
A resident with multiple medical conditions did not receive a prescribed second dose of permethrin cream for suspected scabies because the medication was not available at the time of administration. The nurse reordered the medication, but it was delivered after the resident had been discharged. Facility policy requires medications to be administered as ordered, but this was not followed, resulting in an incomplete treatment regimen.
A resident with multiple chronic conditions did not receive 14 prescribed medications at a scheduled time, and was also given a blood pressure medication outside of ordered parameters, with no documentation or physician notification for these deviations.
Two residents did not receive care according to physician orders and professional standards. One resident experienced delayed administration of glaucoma eye drops and was not provided with the correct size of incontinence briefs, resulting in discomfort and the need for family intervention. Another resident missed scheduled IV antibiotic doses due to lack of IV access, and staff failed to notify the physician about the missed doses or the absence of IV access.
Two residents experienced significant medication errors when a Bisacodyl suppository was administered via the wrong route and a full course of Ertapenem IV antibiotics was not completed as ordered. These errors were confirmed through record review and staff interviews, and were not in accordance with facility policy or physician orders.
A resident admitted with two right abdominal JP drains and multiple complex diagnoses did not have these drains addressed in their care plan. Despite requiring maximal assistance and having intact cognitive function, the care plan lacked measurable objectives and interventions for JP drain management. Staff interviews and policy review confirmed the omission, which placed the resident at risk for insufficient care related to the drains.
A resident with multiple diagnoses, including cellulitis and cancer, did not receive a physician-ordered CBC with differential after the initial blood sample was unusable. Facility staff did not follow up with the laboratory to ensure the test was completed, resulting in the test not being performed as required by facility policy.
A resident with multiple complex medical conditions was admitted with a PIV catheter, but the facility failed to document the removal of the initial catheter and the placement of a new one. Staff interviews confirmed that required details such as timing, site, and reason for catheter changes were missing from the medical record, contrary to facility policy.
A resident with a history of falls and cognitive impairment repeatedly attempted to get out of bed unassisted, but staff failed to ensure the bed alarm was functioning and did not provide adequate supervision or timely intervention, resulting in a severe fall and injury. After the fall, the resident was moved without an RN assessment, contrary to policy. Another resident at high risk for falls was also found with a disconnected bed alarm, and staff did not check its functionality during their rounds.
A resident with multiple health conditions experienced a fall resulting in injuries and a physician-ordered emergent transfer to the hospital. However, a family member refused immediate transfer, causing a 30-minute delay before 911 was called. Facility staff did not notify the physician of the delay, despite policy requiring such notification when treatment is altered or refused.
A resident with intact cognition and multiple neurological diagnoses reported being hit by two CNAs during care. The RN notified the state survey agency and law enforcement within the required timeframe but failed to report the abuse allegation to the Ombudsman as mandated by facility policy and regulations. Staff interviews and policy review confirmed the omission.
A resident with multiple chronic conditions reported numbness and weakness on one side of her face to an RN, who assessed her but did not notify the physician as required by facility policy. The resident continued to experience symptoms and, after reporting them again to another RN, was transferred to the emergency department and diagnosed with Bell's Palsy. The delay in physician notification resulted in delayed care and treatment.
A nurse left a resident's prescribed medication, polyethylene glycol 3350 mixed with water, unattended on the bedside table after forgetting to administer it. The nurse acknowledged the error, and another RN confirmed that medications should not be left unattended, as per facility policy. The resident had multiple medical conditions and was prescribed the medication for bowel management.
A resident with a history of falls and multiple health conditions was admitted without a fall risk assessment being completed as required by facility policy. Staff and the DON confirmed the assessment was missed, despite documentation showing the resident needed significant assistance and was at high risk for falls.
A resident with heart failure and other medical conditions experienced a rapid weight loss, but the facility did not obtain weekly weights as required by the care plan and facility policy. Despite clear documentation and interdisciplinary team instructions to monitor the resident's weight weekly, the next weight was not recorded until almost two weeks later, during which time the resident developed edema and a large weight gain was noted. Facility leadership confirmed that the required weekly weights were not performed, resulting in a delay in care.
A resident with multiple medical conditions experienced symptoms requiring a urinalysis and culture, but the facility failed to ensure the laboratory specimen was picked up and processed. The specimen was collected and stored, but staff did not notify the lab or follow up on the results, and the order was not tracked, resulting in the resident being discharged without the necessary tests completed.
A resident with severe cognitive impairment, epilepsy, and high fall risk was found living in a cluttered room, with multiple boxes, bags, and clothing obstructing the entrance. The clutter, belonging to the roommate, was observed by an LVN and confirmed by the DON, who stated the environment was not comfortable. The resident's care plan required a clutter-free environment due to high fall risk, but this was not maintained.
A resident with a history of neuropathy, malignant melanoma, hypothyroidism, and muscle weakness did not receive prescribed muscle spasm medication after a change in physician orders. An LVN failed to review the updated medication orders, resulting in a delay in administering Cyclobenzaprine when the resident reported muscle spasms. The DON confirmed that medications were not given as ordered, contrary to facility policy.
A resident with a multidrug-resistant E. coli urinary tract infection was placed on contact precautions, but staff failed to post an isolation sign indicating the required PPE at the room entrance, despite facility policy and care plan directives. Staff interviews confirmed the omission and acknowledged that the sign was necessary to inform staff and visitors of the appropriate precautions.
The facility failed to develop comprehensive care plans for residents, including those using CPAP, insulin, and antibiotics, and did not document a resident's preference for female CNAs. This lack of care plans led to potential risks in treatment and unmet resident preferences.
The facility's nursing staff failed to rotate injection sites for insulin and heparin for three residents, leading to potential skin damage and impaired medication absorption. Additionally, a resident did not receive three doses of levothyroxine as ordered, which could affect thyroid function. The Director of Nursing acknowledged these as deficiencies in adherence to professional standards and facility policies.
The facility failed to maintain a safe environment and provide adequate supervision, leading to multiple deficiencies. A resident had unauthorized medication at the bedside, another had a deactivated fall alarm, and several residents had obstructed fall mats. Additionally, post-fall monitoring was not completed for a resident, indicating lapses in safety protocols.
A resident using a home CPAP machine in an LTC facility did not have a physician's order, assessment, or care plan for its use. The CPAP machine and mask were not cleaned according to the manufacturer's guidelines, and staff acknowledged these deficiencies. The resident had diagnoses including COPD, asthma, and obstructive sleep apnea.
The facility failed to accurately account for controlled medications for two residents, leading to discrepancies in documentation. Additionally, a resident with anxiety did not receive alprazolam promptly, and another resident missed doses of levothyroxine, highlighting lapses in medication administration and record-keeping.
A facility failed to respond to a pharmacist's recommendations to limit the duration of PRN lorazepam and define the length of therapy for PRN guaifenesin for a resident with an anxiety disorder. The facility did not act on these recommendations, increasing the risk of inappropriate medication use.
Failure to Continue and Reassess Wound Care for a Draining Craniotomy Incision
Penalty
Summary
The facility failed to reassess the need for continuation of wound care for a resident with a right-sided craniotomy incision that was actively draining and worsening. The resident was admitted with diagnoses including hemiplegia, hemiparesis, acute respiratory failure with hypoxia, tracheostomy dependence, and ventilator dependence, and was documented as lacking decision-making capacity with severely impaired cognition and dependence for personal care. The admission evaluation identified a right-sided craniotomy, and the skin assessment noted the surgical site on the right side of the head. The resident’s wound initially had a dry scab with no drainage, but later assessments documented swelling, clear fluid leaking from the craniectomy incision, pooling of clear liquid in the ear, and a trail of clear liquid from the incision. Subsequent wound monitoring documented scattered scabs, fluid leaking above the ear, blanchable redness, and later moderate serous drainage from the surgical site. On 6/19/2026, the resident was noted with purulent drainage from two areas of the craniectomy incision, swelling above the ear, redness around the incision, and the resident repeatedly placing his hand on the area where the bone flap had been removed. The treatment records showed ordered wound care for the surgical site, including cleansing with NS, applying betadine or povidone-iodine, cadexomer iodine gel, and covering with dry dressing for specified periods. However, the TAR and medication administration audit showed missed or incomplete documentation of treatment on some days, including no treatment documented for one order in May and no sign-off for povidone-iodine on 6/19/2026 and cadexomer iodine on 6/19/2026. Staff interviews confirmed uncertainty about why treatment was not given, and one treatment nurse stated the team did not verify with the doctor whether wound care should continue. The DON stated staff should call the doctor and verify the need to continue treatment, and the MD stated he was not aware that wound treatment had not been provided. On 6/20/2026, the wound assessment documented purulent drainage, dehiscence, and maggots coming out of the ear canal, and the resident was transferred to the hospital for further evaluation.
Unnecessary Psychotropic Medication Use Without Documented GDR Rationale
Penalty
Summary
The facility failed to ensure Resident 14’s psychotropic medication regimen was free from unnecessary use when Zoloft 50 mg daily was continued without a documented detailed clinical rationale for ongoing use and without an attempted gradual dose reduction (GDR). Resident 14 had diagnoses including depression and was originally prescribed Zoloft for depression manifested by verbalization of sadness. The resident’s care plan, initiated in September 2025, identified antidepressant use with a goal of decreased episodes of signs and symptoms of depression. Record review showed that Resident 14’s MDS assessments from October 2025 and later documented no symptoms of feeling down, depressed, or hopeless, while the MARs from January through mid-June 2026 showed daily administration of Zoloft 50 mg. The MAR review also showed zero documented behaviors of depression manifested by verbalization of sadness in January, February, April, May, and June 2026, and one documented behavior in March 2026. A psychiatric progress note dated 4/14/2026 stated that no recent behavior disturbances manifested by verbalization of sadness had been observed and that GDR was not indicated because the benefits of current treatment outweighed the risks of dose reduction. During interview and record review, the DON acknowledged that the resident had almost no documented behaviors since January 2026, no documented depressive symptoms on MDS assessments since October 2025, and that the care plan goals had been met. The DON also acknowledged that the psychiatric note did not provide a specific clinical rationale for continuing Zoloft at the original dose or identify a clinical contraindication to GDR. The facility policy required psychotropic medications to remain in use only when GDR and behavioral interventions had been attempted or were clinically contraindicated, and required documentation of the adequate clinical indication and necessity for the medication.
Indwelling Catheter Care and Monitoring Failures
Penalty
Summary
The facility failed to ensure appropriate care and services for residents with indwelling urinary catheters. For one resident admitted with diagnoses including surgical aftercare following genitourinary surgery, penile abscess, Fournier gangrene, and abnormal urine findings, the record showed an indwelling catheter order to drainage bag and an order to change the catheter if blockage, leakage, removal, or dislodgement occurred. The care plan included monitoring for catheter-related trauma and signs and symptoms of UTI, including no urine output, and the resident was also on a UTI care plan with interventions to monitor intake and output and report signs and symptoms of UTI. Observation and interviews showed the resident’s catheter had been leaking for about a week, with staff and family aware of the issue. The resident stated he was uncomfortable because he was wet, and family reported the catheter was still leaking. A CNA reported that on one shift the drainage bag had zero urine output for the entire shift and urine had leaked into the resident’s brief. Nursing staff and the treatment nurse acknowledged the catheter was bypassing, but there was no documented evidence that the physician was notified through SBAR when the catheter was bypassing and could not be changed by staff. The resident later developed abdominal distention and urinary retention and was sent to the hospital, where the record noted hospitalization for urinary retention and abdominal discomfort. The facility also failed to follow its intake and output monitoring process for this resident. The facility’s policy required urine output to be measured and recorded for each patient with an indwelling catheter, and staff stated the CNA was to measure output and the licensed nurse was to document it every shift. However, multiple shifts had no documented measured catheter output, and nursing staff acknowledged the output had not been monitored and documented since admission. Staff and management stated that measuring and documenting catheter output was the way to ensure the catheter was functioning properly, and they confirmed the facility process was not followed. For a second resident with neurogenic bladder and an indwelling catheter, observation showed the catheter tubing was in a dependent loop with stagnant, partially cloudy urine, and the tubing was positioned above the resident’s bladder. The LVN stated the tubing should drain by gravity and should not be coiling to prevent UTI. The DON stated catheter tubing must be positioned below the bladder to prevent urine backflow, which could potentially lead to infection. The facility policy also stated catheter tubing should be positioned lower than the resident’s body to facilitate drainage. The resident’s catheter was therefore not maintained in a manner consistent with the facility’s stated catheter care practices.
Controlled Substance Reconciliation and Documentation Failures
Penalty
Summary
The facility failed to reconcile two medication emergency kits containing controlled substances in Medication Room Station 1 and Medication Room Station 2. During observation and interview, one refrigerated eKIT labeled 35 in Medication Room Station 2 contained lorazepam but had no accountability log showing controlled substance inventory reconciliation at each shift change for June 2026. A second refrigerated eKIT labeled 69 in Medication Room Station 1 also contained lorazepam and likewise had no accountability log for shift-by-shift reconciliation during June 2026. Both LVNs interviewed stated that controlled substances in eKITs should be reconciled at every shift and acknowledged that these kits were not reconciled as required. The facility also failed to account for two controlled substance doses in Medication Cart 2 Station 2 for two residents. For one resident with diagnoses including polyneuropathy, the accountability log for pregabalin 75 mg showed 11 tablets should have been present, but 12 tablets were found in the bubble pack, and there was no documentation of an additional administration after the recorded time. For another resident with diagnoses including seizures, the accountability log for lacosamide 100 mg showed 48 tablets should have been present, but 47 tablets were found in the bubble pack, and there was no documentation of an additional administration after the recorded time. During interview, the LVN stated that one pregabalin dose had been prepared and signed for in advance of administration, and that one lacosamide dose had been administered but not signed on the accountability record. The LVN stated the facility policy required controlled substance doses to be documented immediately after preparation or administration. The DON also stated that the eKITs containing controlled substances were not reconciled at every shift and that the LVN failed to document preparation of the controlled substance doses in a timely manner.
Medication Administration Errors Involving Expired Insulin and Held Amiodarone Orders
Penalty
Summary
The facility failed to prevent significant medication errors involving insulin and amiodarone. For one resident with type 2 diabetes mellitus, the record showed an order for insulin aspart (Novolog) by sliding scale every 8 hours. During medication cart observation, an open Novolog FlexPen for that resident was found stored at room temperature with a handwritten opening date of 5/13/2026 and a discard date of 28 days later. Staff stated the pen had expired on 6/10/2026, but it remained in the cart and was still used. The MAR showed that two doses of this expired insulin were administered by two different LVNs on 6/14/2026. The same review and interview confirmed that the expired insulin was not removed from Medication Cart 2 Subacute and was administered after the beyond-use date. The LVN stated expired insulin should have been discarded and replaced before expiration, and that giving expired insulin would not effectively control blood sugar. The DON acknowledged that several LVNs failed to remove the expired pen from the cart, resulting in two doses of expired insulin being given to the resident. For another resident with ESRD, dependence on HD, hypertensive heart disease, A-fib, and hypotension, the physician ordered amiodarone 200 mg, two tablets by mouth in the morning, with instructions to hold the medication if SBP was less than 110 or HR was less than 60. Review of the MAR showed amiodarone was documented as administered on two occasions when the resident’s SBP was 102 and 108. During interview, the MDS nurse and RN confirmed the medication was not held despite the ordered parameter, and the DON confirmed the medication was not administered in accordance with the physician’s order.
Expired and Unlabeled Medications Found in Storage Areas
Penalty
Summary
Expired and improperly stored medications were found in multiple medication storage areas during observation, interview, and record review. In Medication Room Station 1, an open multi-dose Epogen vial for Resident 80 was stored in the refrigerator with remaining medication inside, but it was not labeled with the date it was first punctured or opened. RN 4 stated the vial was open and used, that the opening date was unknown, and that it was considered expired because the date of first use could not be verified. In Medication Cart 2 Station 1, an open insulin Lispro Kwikpen for Resident 44 was found in the refrigerator with labels showing it had been opened and should be discarded after 28 days, yet it remained stored past that time. In the same cart, an open levalbuterol inhalation solution foil pouch and an open dorzolamide with timolol ophthalmic solution foil pouch for Resident 57 were found at room temperature without labels showing when the pouches had been opened. LVN 9 stated the insulin Lispro pen had expired and remained in the refrigerator, and also stated the inhalation and ophthalmic products were not labeled with opening dates. In Medication Cart 2 Subacute, an open insulin Novolog Flexpen for Resident 123 was found stored at room temperature with a handwritten label showing the date it was opened and the discard date, but it remained in use after the discard date had passed. LVN 4 stated the pen was considered expired and had not been removed from the cart. During interview, the DON acknowledged that expired medications should be removed from medication carts and rooms, and that multi-dose medications such as insulin pens and Epogen vials should be labeled with the date use first began to determine when they expire. Facility policy also stated that when opening a multidose container, the date must be placed on the container, and expired medications must be removed from active supply and destroyed.
Call Lights Not Kept Within Reach for Two Residents at Fall Risk
Penalty
Summary
The facility failed to keep the call light within reach for two residents who were identified as being at risk for falls. Resident 39 was admitted with diagnoses including type 2 diabetes mellitus with hyperglycemia, generalized muscle weakness, and cognitive communication deficit. The resident’s H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS showed severe cognitive impairment, dependence or maximal assistance with mobility and ADLs, and high fall risk. The care plan directed staff to keep the call light within reach and encourage use for assistance as needed. During a concurrent observation and interview, a CNA found Resident 39’s call light on the bottom part of the bed between the side rail and mattress. The CNA stated the resident would not have been able to call for help and could have potentially fallen trying to reach the call light. In a later interview and record review, an LVN confirmed the resident was at high risk for falls, stated the call light was not within reach, and said the care plan and the facility’s Resident Call System policy were not followed. The DON also stated the call light was not within reach, that this would delay assistance, and that the resident could potentially fall trying to reach it. Resident 110 was admitted with diagnoses including cervical spinal stenosis, generalized muscle weakness, and history of falling. The resident’s H&P indicated the resident had capacity to make decisions, and the MDS showed intact cognitive function with partial/moderate assistance needed for bed mobility, transfers, dressing, toilet use, and personal hygiene. The care plan also directed staff to keep the call light within reach. During observation, the resident’s call light and bed remote control were hanging down below and between the left side bed rail and mattress. The CNA stated the resident would not have been able to call for assistance and could have potentially fallen trying to reach the call light. The LVN and DON both stated the resident was at risk for falls, could not reach the call light, and that the care plan and Resident Call System policy were not followed.
Failure to Notify Physician of Catheter Bypassing and No Urine Output
Penalty
Summary
The facility failed to immediately notify the physician of a significant change in condition for a resident with an indwelling catheter when the catheter was bypassing and there was no urine output in the drainage bag for an entire day shift. The resident was admitted with diagnoses including aftercare following genitourinary surgery, abscess of the corpus cavernosum and penis, Fournier gangrene, and other abnormal urine findings. The resident’s records showed an indwelling catheter order and a separate order to change the catheter if there was blockage, leakage, removal, or dislodgement. The care plan also directed staff to change the catheter for leaking and to monitor, document, and report to the physician signs and symptoms of UTI, including no urine output. During observation and interviews, the resident stated the catheter had been leaking urine for about a week and that staff were aware, but told him they could not do anything because he needed to see the urologist to have the catheter changed. A family member stated the resident had been complaining since the prior week that the catheter was leaking and that she told a nurse, who said the catheter could not be changed and the resident needed to see the urologist. A CNA stated that on the day shift the drainage bag had zero urine output for the entire shift and all urine had leaked into the resident’s brief, and that the resident’s catheter was still leaking. The LVN stated she was not aware of any issues reported by staff or family regarding the catheter. The treatment nurse stated the catheter had bypassing issues and that only the urologist could change it. The MDS nurse stated bypassing means the catheter is not functioning properly and that if a catheter is bypassing with no urine in the drainage bag for an entire shift, it should be reported to the physician as an SBAR. The MDS nurse stated there was no documented evidence that the physician was notified between admission and the evening shift of the following day. The resident later developed abdominal distention and was found to be retaining 600 mL of urine and was sent to the hospital for further evaluation. The DON stated the bypassing with no urine collection for an entire shift was a change in condition that should have been reported to the physician, but was not.
Unsafe Room Conditions and Obstructed Floor Mat
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents who were identified as high fall risks. One resident had diagnoses including dementia, epilepsy, muscle weakness, and a history of falling, and the record showed multiple recent falls, including an unwitnessed fall with facial redness, bruising to the nose, bleeding lips and gums, dislodged front teeth, arm abrasion with bleeding and swelling, immobility of the left elbow, and swelling to the left knee. The resident’s care plan called for a safe environment with floors free from spills, and staff interviews confirmed the resident had a recent fall with major injuries and remained a high fall risk. During observation, the resident was seen sitting up in bed and eating while unattended by staff, with a puddle of clear liquid on the floor between the foot of the bed and the wall. A LVN entered and exited the room while the puddle remained. Later, a CNA was observed leaving the resident unattended while the spill was still present. Staff interviews indicated the spill should have been identified and cleaned immediately, and the DON reviewed the facility policy stating liquid spills should be cleaned right away rather than waiting for housekeeping. A second resident, who had diagnoses including dementia, head contusion, dysphagia, muscle weakness, alcohol dependence, and a history of falling, had a care plan calling for bilateral floor mats to reduce injury from falls and to keep the environment free from spills and clutter. During observation, a chair and trash bin were placed on top of the floor mat on the resident’s left side of the bed. The 1:1 sitter stated the objects had been on the mat since the start of the shift, while an LVN stated objects should not be placed on top of the mat because they could cause injury. The DON also stated floor mats should be free from objects because a resident could land on them and be injured.
Incorrectly Labeled Enteral Flush Bag
Penalty
Summary
The facility failed to provide appropriate care for a resident receiving enteral feeding by incorrectly labeling the flushing bag connected to the kangaroo pump. Resident 75 was admitted and readmitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction affecting the left non-dominant side, generalized muscle weakness, and encounter for attention to gastrostomy. The resident’s H&P stated the resident could make needs known but could not make decisions, and the MDS indicated severe cognitive impairment, dependence on staff for mobility and ADLs, and the ability to make self-understood and understand others. The resident had orders for Diabetisource AC at 55 mL/hr for 20 hours and for water flushes at 35 mL/hr for 20 hours via kangaroo pump. During observation, the Diabetisource bag and flush bag were hanging from the pump pole, and the flush bag contained clear liquid but was labeled as Diabetisource at 35 mL/hr. An LVN observed that the flush bag was labeled incorrectly and stated it should have included the rate, time, date, and the correct solution name, water instead of Diabetisource. The DON stated the flush bag was incorrectly labeled as Diabetisource instead of water, which could cause confusion with delivery of the feeding and potentially lead to an error.
Unlabeled Oxygen Tubing for Two Residents
Penalty
Summary
The facility failed to ensure that oxygen via nasal cannula tubing was labeled with the date it was last changed for two residents receiving respiratory care. Resident 30 was admitted with acute respiratory failure with hypoxia, type 2 diabetes mellitus with hyperglycemia, and generalized muscle weakness. Resident 30’s H&P indicated the resident had the capacity to make decisions, and the MDS showed intact cognitive function and that the resident required maximal assistance with mobility and ADLs. During a concurrent observation and interview, the resident’s nasal cannula was observed without a label showing the date it was started or last changed. The LVN stated the tubing should be labeled for infection control precautions and that it is changed weekly or as needed, and that without a label staff would not know when it was changed. Resident 184 was admitted with COPD with acute exacerbation, generalized muscle weakness, and a history of falling. The resident’s H&P indicated the resident had the capacity to understand and make decisions for herself. During a concurrent observation and interview, Resident 184’s nasal cannula was also observed without a label showing the date it was started or changed. The LVN stated the tubing should be labeled for infection control precautions and that it is changed weekly or as needed, and that without a label staff would not know when it was changed. The DON stated that if the nasal cannula is not labeled with the date it was started, staff are unable to determine when it is due for replacement and this prevents monitoring timely tubing changes in accordance with the facility’s infection prevention practice.
Lack of HgA1c Monitoring for Resident on Insulin
Penalty
Summary
The facility failed to ensure adequate monitoring of HgA1c levels for a resident with DM2 who was prescribed Regular insulin per sliding scale SQ every 6 hours. The resident’s admission record showed DM2, and the MDS indicated the resident had diabetes and was using insulin. The order summary and MAR confirmed the insulin regimen was in place, but the clinical record did not contain any laboratory tests or results for HbA1c since the resident’s insulin order began on 7/13/2025. During interview and record review, the DON reviewed the resident’s clinical record and acknowledged the resident had DM2 and was prescribed Regular insulin per sliding scale. The DON later stated that after a thorough search, the record did not contain baseline or subsequent HgA1c monitoring since admission. The DON stated that HgA1c monitoring was important to determine whether insulin therapy was effective and whether medication changes were needed, and that residents with DM2 and insulin should have baseline HgA1c levels when admitted and monitoring every 3 to 6 months. The CP also stated that HgA1c levels should be monitored every 3 months, and for stable residents every 6 to 12 months, because blood sugar checks alone were not enough to determine medication effectiveness.
Missed Meal During Appointment
Penalty
Summary
The facility failed to ensure that Resident 12 received a suitable meal when the resident had a scheduled appointment during lunchtime. Resident 12 was admitted with diagnoses including cerebral infarction, diabetes, and muscle weakness, and the record showed significant memory loss, wheelchair use, impairment in both arms and legs, and dependence on caregivers for all daily activities, including feeding assistance. The care plan directed that the resident receive the ordered diet, and the SBAR noted a 16-pound weight loss over six months. During observation, medical transport arrived while Resident 12 was in the room, and the resident's meal tray arrived shortly afterward. LVN 2 stated that because of the appointment, Resident 12 could not be fed a meal and was given Ensure instead. LVN 2 later stated the appointment should have been communicated to the kitchen so a snack pack could be prepared before the appointment. The RD stated Ensure should not replace a meal, and the DD confirmed the kitchen was not aware of the appointment and no sack lunch was prepared. The DON stated the Meals Packed to Go policy was not followed and that Ensure is not an appropriate replacement for a meal.
Failure to Follow Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions were followed when an LVN administered medications to a resident with wounds. During an observation on 6/15/2026 at 9:35 a.m., the LVN was seen sanitizing her hands, entering Resident 93’s room, and administering 14 medications without wearing gloves and a gown, even though an EBP sign was posted at the room entrance. Resident 93 had been placed on EBP because of wounds, and the resident’s diagnoses included malignant neoplasm of skin. During interview, the LVN stated gloves and a gown should have been worn when giving medical treatments to the resident and acknowledged she failed to do so. The DON also acknowledged the resident was on EBP due to wounds, stated residents with wounds are at increased risk of infections, and stated the LVN failed to follow the facility’s P&P for EBP and infection control by not wearing gloves and a gown during medication administration.
Failure to Monitor Residents After Change of Condition
Penalty
Summary
The facility failed to follow professional standards of nursing practice for Resident 5 after a change of condition on 6/7/2026 related to an alleged physical aggression with Resident 6. Resident 5 was admitted on 5/19/2026 with diagnoses including metabolic encephalopathy, muscle weakness, and depression, and the MDS dated 5/26/2026 indicated the resident’s cognitive skills for daily decision making were severely impaired. The COC form documented that at 11:13 a.m. on 6/7/2026, Resident 5 was heard yelling in the station A hallway and allegedly reported getting hit on the arm by Resident 6. During interview and record review with the ADON on 6/10/2026, Resident 5’s progress notes from 6/7/2026 through 6/10/2026 were reviewed. The ADON stated residents should be monitored every shift for 72 hours after a change of condition, but the notes showed no documented monitoring for Resident 5 on the 11 p.m. to 7 a.m. shift on 6/7/2026, the 3 p.m. to 11 p.m. shift and 11 p.m. to 7 a.m. shift on 6/8/2026, and the 11 p.m. to 7 a.m. shift on 6/9/2026. The ADON stated care not documented was considered not provided and that failure to document monitoring after a change of condition could put Resident 5’s safety at risk. The facility also failed to appropriately assess and monitor Resident 6 after the same event; Resident 6 was admitted on 1/6/2022 with diagnoses including cerebral infarction, hemiplegia, and type 2 DM, the MDS indicated intact cognitive skills for daily decision making, and the COC form stated Resident 6 allegedly hit Resident 5 on the right arm. The ADON reviewed Resident 6’s progress notes and found no documented monitoring for the 3 p.m. to 11 p.m. shift on 6/8/2026, stating that care not documented was considered not provided and that failure to document monitoring after a change of condition could put Resident 6’s safety at risk.
Inaccurate MDS Skin Assessment
Penalty
Summary
Facility failed to ensure an accurate assessment was conducted for one resident when the 5/25/2026 MDS did not accurately reflect the resident’s skin condition. The resident was admitted on 5/15/2026 with diagnoses including hemiplegia, hemiparesis following cerebral infarction, type 2 DM, and muscle weakness. The admission Admit/Readmit Evaluation dated 5/15/2026 did not indicate that the resident had a DTI. The 5/25/2026 MDS indicated the resident had severely impaired cognitive skills for daily decision making, was dependent on staff for rolling left and right, and had one unstageable DTI that was present on admission. During interview and record review, the MDS Nurse stated the resident’s DTI developed at the facility and that the MDS assessment on skin condition was inaccurate. The DON stated the MDS was one of the tools used for the resident’s care plan and acknowledged the facility failed to accurately document the resident’s skin conditions on the MDS assessment following admission.
Delayed Documentation of Resident Assessment
Penalty
Summary
The facility failed to ensure the medical record for one resident was maintained in accordance with accepted professional standards and practice because licensed nurses did not document the resident’s assessments in a timely manner. The resident was admitted with diagnoses including metabolic encephalopathy, muscle weakness, and depression, and the MDS dated 5/26/2026 indicated the resident’s cognitive skills for daily decision making were severely impaired. After a change of condition on 6/7/2026, the resident was heard yelling in the hallway and allegedly reported being hit on the arm by another resident. The ADON stated the resident should be monitored every shift for 72 hours after a change of condition, but documented assessments performed on 6/8/2026 at 6:33 a.m. and on 6/9/2026 at 6:39 a.m. were not entered until 6/10/2026, with delays of two days, nine hours, and one minute, and 32 hours and 58 minutes. The ADON and DON both stated the assessments were not documented timely and were not identified as late entries, despite the facility policy requiring late entries to be made in a timely manner and to include the date and time of the late entry and the date of the entry being documented.
Care Plan Not Revised After G-Tube Dislodgement
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident after the resident’s gastrostomy tube became dislodged and the resident was transferred to the general acute care hospital. The resident had been admitted originally on 11/16/2023 and readmitted with diagnoses including encounter for attention to gastrostomy, bipolar disorder, and type 2 diabetes mellitus. The resident’s MDS dated 5/4/2026 showed intact cognitive functioning, dependence on staff for eating and showers, and maximal assistance needed for oral hygiene and personal hygiene. A Change of Condition form dated 5/15/2026 documented that the resident’s G-tube was in the process of dislodgement, with redness and drainage at the stoma site, and that the resident was transferred to the GACH at 10:06 p.m. During interview and record review, the MDS Coordinator stated the care plan was not revised to reflect the G-tube dislodgement, and the DON stated the care plan should have been revised after the dislodgement and hospital transfer to reflect services needed for G-tube care and to prevent accidents. The facility policy stated that comprehensive care plans are developed, reviewed, and revised by the interdisciplinary team to meet each resident’s needs.
Failure to Document and Monitor Change in Resident Wandering Behavior
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in response to a resident’s new wandering behavior. Resident 1, admitted with diagnoses including type 2 diabetes mellitus, COPD, and cerebral infarction, had a prior Wandering/Elopement Risk Evaluation dated 2/18/2026 indicating no risk for wandering or elopement. The resident’s H&P dated 2/19/2026 documented fluctuating capacity to understand and make decisions, while an MDS dated 2/25/2026 indicated intact cognitive skills for daily decision making. On 3/13/2026, Resident 1 was reported wandering into another resident’s room multiple times, which represented a change from the resident’s prior status. On 3/13/2026, Resident 2, who was cognitively intact, reported that Resident 1 entered her room three times, and stated that Resident 3 reported these incidents to a licensed nurse. LVN 1 confirmed that Resident 3 reported Resident 1 being inside the rooms of Residents 2 and 3 and stated that this wandering behavior was new for Resident 1. LVN 1 reported the incident to the licensed nurse in charge of Resident 1 on the 11 p.m. to 7 a.m. shift. However, there was no Change of Condition (COC) Evaluation form completed for Resident 1 on 3/13/2026, and there was no documented evidence that the attending physician or the resident’s family member were notified of this new wandering behavior, despite facility policy requiring immediate consultation with the physician and notification of the resident representative when there is a significant change in physical, mental, or psychosocial status. Further record review and interviews showed that the facility did not document ongoing assessment and monitoring of Resident 1 following this change in condition. LVN 3 stated that Resident 1’s wandering behavior was a change in condition and that the resident should have been monitored every shift for 72 hours, but Resident 1’s progress notes lacked documentation of monitoring on multiple shifts on 3/14/2026, 3/15/2026, and 3/16/2026. LVN 3 and the DON both acknowledged there was no confirmed documented evidence of monitoring on these identified shifts. The facility’s Documentation Policy required initiation of 72-hour charting for a significant change in physical, mental, or psychosocial status, and the Notification of Changes policy specified use of the SBAR charting form as the documentation of a resident’s change in condition. These policies were not followed for Resident 1’s new wandering behavior.
Failure to Develop and Implement Person-Centered Care Plan for ADL Assistance, Constipation, and Insulin Refusal
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to develop and implement a complete, person-centered care plan for a resident with multiple medical conditions, including sequelae of nontraumatic intracerebral hemorrhage, diabetes mellitus, generalized weakness, glaucoma, and poor vision. The resident was admitted with a controlled carbohydrate, no-added-salt diet and regular texture with thin liquids. The resident’s MDS showed intact cognitive skills for daily decisions but indicated the resident required maximum assistance from staff for all ADLs and was frequently incontinent of bowel and bladder. The care plan for ADLs, dated 11/10/2025, only stated that the resident required assistance with eating and did not specify what type or level of assistance would be provided, despite the MDS indicating a need for maximum assistance. The glaucoma care plan indicated encouraging independence with ADLs and assisting as needed, but did not clearly identify that maximum assistance with eating was required. Family Member 1 reported that the resident was visually impaired and that staff would deliver the food tray, verbally identify the items on the tray, and then leave the resident to eat independently. FM 1 also stated that some of the foods staff said were on the tray were not actually present. During interviews, LVN 1 and the MDS nurse confirmed that the MDS documented the resident’s need for maximum assistance with eating and that the ADL care plan did not include specific interventions describing the type of assistance to be provided during meals. The MDS nurse and the DON both acknowledged that the care plan for glaucoma and ADLs should have specified that the resident required maximum assistance from staff for eating and that the care plan should have been individualized with specific interventions. Surveyors also found that the facility failed to implement the resident’s care plan for constipation and failed to develop a care plan addressing the resident’s refusal of insulin glargine. The resident had PRN orders for bisacodyl suppositories every 12 hours as needed for constipation and milk of magnesia if no bowel movement occurred in three days. Bowel movement records showed no bowel movements on multiple dates, yet the MAR indicated that bisacodyl and milk of magnesia were not administered on those days. LVN 1 confirmed that the resident did not have bowel movements on those dates, that the ordered constipation medications were not given as specified, and that the care plan intervention to administer medications as ordered was not followed. Additionally, the MAR documented that the resident refused insulin glargine on two dates, but there was no corresponding care plan addressing this refusal. LVN 1, the MDS nurse, and the DON all stated that a care plan should have been developed for the resident’s refusal of insulin glargine, consistent with the facility’s policy requiring the comprehensive care plan to identify declined services, associated risks, and IDT efforts when a resident refuses treatment.
Failure to Follow Medication Orders and Timely Administration for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services in accordance with physician orders and facility policy for one resident with multiple medical conditions, including diabetes mellitus, sequelae of intracerebral hemorrhage, and generalized weakness. The resident was admitted with PRN orders for bisacodyl suppositories every 12 hours as needed for constipation and milk of magnesia (MOM) if no bowel movement occurred in three days. Point of Care bowel movement records showed no bowel movements on several specific dates, yet the Medication Administration Record (MAR) indicated that bisacodyl and MOM were not administered on those days. During interview, an LVN confirmed that the resident had no bowel movements on those dates and that neither bisacodyl nor MOM was given as ordered, and the DON stated that the physician’s orders were not followed and that the medications should have been offered and administered or refusals documented. The facility also failed to ensure accurate documentation and administration of bisacodyl on another date. A Change of Condition note documented that bisacodyl was administered to the resident’s frontal private area on a specific date, but the MAR did not show administration of bisacodyl on that date. The DON stated that an LVN administered the bisacodyl but did not document it on the MAR, and that the ADON later documented the administration because the LVN had not done so. Facility policy required that the person who prepares the dose must be the one who administers it and that the individual who administers the medication must record the administration on the MAR directly after giving the medication, including specific documentation requirements for PRN medications. The facility further failed to follow physician orders for insulin glargine and to administer other scheduled medications within the facility’s required time frame. The resident had an order for daily insulin glargine to be held only if blood sugar was less than 100 mg/dl, but the MAR showed that insulin glargine was not administered on two dates when the resident’s blood sugar readings were above 100 mg/dl. An LVN and the DON both acknowledged that insulin glargine should have been administered on those dates and that it was not. Additionally, audit reports showed that enoxaparin, metformin, and metoprolol, all ordered on specific twice-daily schedules, were administered significantly later than the scheduled times on multiple days. The LVN and DON both stated that medications were supposed to be administered within one hour before or after the scheduled time, and that these medications were given outside that window, contrary to facility policy on timely medication administration. Facility policies on administering medications, preparation and general guidelines, and insulin administration all required that medications be administered in accordance with written prescriber orders, that medications be given within 60 minutes of the scheduled time (except for meal-related orders), and that insulin type, dosage, and administration be verified against the physician’s order. The documented late administrations of enoxaparin, metformin, and metoprolol, the missed doses of insulin glargine when blood sugars were above the hold parameter, the failure to administer bisacodyl and MOM when bowel movement criteria were met, and the failure to document a given dose of bisacodyl on the MAR collectively demonstrate that the facility did not follow its own policies or the physician’s orders for this resident’s medications.
Delayed Response to Call Lights for Resident Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ call lights were answered in a timely manner, resulting in delays in assistance for two residents. Resident 1 was admitted with diagnoses including sequelae of nontraumatic intracerebral hemorrhage, diabetes mellitus, and generalized weakness, and was documented as alert and oriented with intact cognitive skills but requiring maximum assistance for all ADLs and being frequently incontinent of bowel and bladder. According to the resident’s family member, on one occasion when Resident 1 experienced an episode of vomiting, the resident pressed the call light multiple times to request assistance, but no staff responded for 30 to 60 minutes. Resident 3 was admitted with a right femur neck fracture, generalized muscle weakness, and dysphagia, and had the capacity to understand and make decisions, with the MDS later indicating moderately impaired cognitive skills for daily decisions, maximum assistance needs for toileting and showering, and frequent bowel and bladder incontinence. Resident 3 reported that on the evening shift, staff sometimes took a long time to respond to the call light for incontinent care, and if no one answered, the resident would call a family member to request help. The family member confirmed that the resident often called in the evening when call lights were not answered for incontinence care, prompting the family member to call the facility to ask staff to change the resident’s incontinent brief. The DON acknowledged that delays in responding to call lights can delay meeting residents’ needs and can possibly cause skin breakdown such as pressure ulcers. The facility’s policy on the resident call system stated that the facility is adequately equipped to allow residents to call for staff assistance through a communication system relaying calls directly to staff or a centralized work area from residents’ bedside, floor, or toileting facilities.
Failure to Notify Resident Representative of COVID-19 Test Result
Penalty
Summary
The facility failed to notify a resident’s designated family member and POA of the resident’s COVID-19 test result after the family member specifically requested the test. The resident was admitted with diagnoses including sequelae of nontraumatic intracerebral hemorrhage, diabetes mellitus, generalized weakness, glaucoma with poor vision, and was documented as alert, oriented, and cognitively intact but requiring maximum assistance with ADLs. On the date of the change in condition, an LVN reported to an RN that the resident had vomited, and the RN notified the resident’s family member, who then requested that the resident be tested for COVID-19. The RN performed the COVID-19 test, which was negative, but there was no documentation in the resident’s medical record that the family member/POA was informed of the result. During interviews, the family member stated she was not informed of the test result, and both the LVN and RN confirmed there was no documentation of notification to the family member, despite acknowledging the importance of doing so, particularly because the test had been requested by the family member. The DON also stated that the RN should have documented that the family member was notified and that accurate and complete medical records and informing the resident and representative are rights. The facility’s Notification of Changes policy indicated that the SBAR form serves as documentation of communication with the physician and resident representative, and that progress notes should be used for other necessary information not on the form.
Incomplete Change of Condition Documentation for Resident Receiving Bisacodyl Suppository
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one of three sampled residents by not fully completing a Change of Condition (COC) document. The resident was admitted with diagnoses including sequelae of nontraumatic intracerebral hemorrhage, diabetes mellitus, and generalized weakness. A History and Physical dated shortly after admission documented that the resident was alert and oriented to person, place, and time. A subsequent Minimum Data Set indicated the resident’s cognitive skills for daily decision-making were intact and that the resident required maximum assistance for all ADLs. On the date of the documented change in condition, the COC form recorded that a bisacodyl suppository was inserted into the resident’s frontal private area, and the section for the date of the last bowel movement was left blank. A family member reported that a suppository had been inserted in the wrong area. During interview and concurrent record review, an LVN confirmed that the COC did not include the date of the last bowel movement to justify the use of bisacodyl and stated the importance of accurate medical records to ensure appropriate treatment. The DON stated that the responsible LVN should have completed the COC to ensure a complete and accurate medical record. The facility’s documentation policy and SBAR Charting Form instructions require that relevant findings be documented in the clinical record and that all sections of the form be completed, or marked N/A if not applicable.
Failure to Monitor and Document Blood Glucose and Hypoglycemia per Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of nursing practice for monitoring and documenting blood glucose and hypoglycemia in a resident with type 2 diabetes mellitus. The resident was admitted with diagnoses including type 2 diabetes, major depressive disorder, and essential hypertension, and had severely impaired cognitive skills for daily decision making per the MDS. Physician orders dated 4/7/2023 required licensed nurses to monitor the resident’s blood glucose every four hours, and orders dated 9/9/2025 required monitoring for signs and symptoms of hypoglycemia each shift, with documentation of the presence or absence of those signs and symptoms in the medical record. The resident’s care plans for hypoglycemic medications and type 2 diabetes directed staff to monitor blood sugar per physician orders and to monitor, document, and report signs and symptoms of hypoglycemia. Record review showed that the resident’s blood sugar was not monitored and documented every four hours as ordered. The MAR for 12/1/2025 to 12/31/2025 contained no evidence that blood sugar checks were performed every four hours for 21 days. The Blood Sugar Summary for 12/1/2025 to 12/21/2025 showed blood sugar levels were taken and documented four times a day instead of every four hours (six times a day). During interview, the LVN confirmed that the documentation did not show every-four-hour monitoring and stated that care not documented was considered not provided. The DON also confirmed there was no documented evidence of blood sugar monitoring every four hours, and acknowledged that the facility failed to ensure the resident’s health status was monitored according to physician orders. The deficiency also includes a failure to document the resident’s hypoglycemia and related signs and symptoms in the MAR during a documented change of condition. On 12/21/2025, an SBAR COC form documented that the resident was observed with labored breathing, altered level of consciousness, and a blood sugar level of 45 mg/dL at 4:50 a.m., and that the resident received intramuscular glucagon and oral glucose gel before transfer to an acute care hospital. However, the DON stated that the resident’s signs and symptoms of hypoglycemia during this change of condition were not documented in the MAR. Facility policies on diabetes care and documentation required monitoring for complications of diabetes, incorporation of physician-ordered blood glucose parameters into the MAR and care plan, identification and reporting of changes in condition such as hypoglycemia, and documentation of relevant findings in the clinical record, which were not followed in this case.
Unauthorized Hypoglycemia Treatment and Missing MAR Documentation
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when staff administered hypoglycemia treatments without proper orders and documentation. The resident, admitted with diagnoses including type 2 diabetes mellitus, major depressive disorder, and essential hypertension, had a discontinued order for glucose gel 40% as of 1/15/2019 and an active order for glucagon 1 mg IM for blood sugar levels less than 70 mg/dL as of 5/11/2024. The resident’s MDS dated 10/24/2025 showed severely impaired cognitive skills for daily decision making, and the care plan for diabetes, last revised on 12/17/2025, directed licensed nurses to provide diabetes medications according to physician orders and to monitor, document, and report signs and symptoms of hypoglycemia. On 12/21/2025, during a change of condition, the resident was observed with labored breathing, altered level of consciousness, and a blood sugar level of 45 mg/dL at 4:50 a.m. The SBAR Communication for change of condition form documented that the resident received glucagon 1 mg IM and glucose gel 40% and was transferred to an acute care hospital. RN 1 stated she witnessed an LVN administer both glucagon 1 mg and glucose gel 40% during this hypoglycemic episode. LVN 2 confirmed that the glucose gel 40% order had been discontinued and that the resident was given glucose gel without an active physician order. Review of the MAR for December 2025 showed no documented administration of glucagon on the date of the event, despite its use being recorded on the change of condition form. The DON stated that physician orders are required before administering medications and that medications given must be documented on the MAR, and acknowledged the failures to obtain an order for glucose gel and to document the glucagon administration.
Failure to Administer Ordered Medication for Suspected Scabies
Penalty
Summary
A deficiency occurred when the facility failed to administer permethrin external cream as ordered for a resident who was suspected of having scabies. The resident had been admitted and readmitted with multiple diagnoses, including gastrostomy, ADHD, and gastro-esophageal reflux disease. Physician orders were in place for contact isolation, monitoring of skin rashes, and the application of permethrin cream from the neck down to the toes for prophylactic treatment. The order specified that the cream should be applied in the evening, left on for 12 hours, and then washed off in the morning. On the scheduled date for the second application of permethrin cream, the Medication Administration Record (MAR) indicated that the medication was not found and had to be reordered. The nurse involved confirmed that the cream was unavailable at the time and that she reordered it. The Director of Nursing (DON) reviewed the records and confirmed that while the first dose had been administered, the second dose was not given because the medication was not available. The DON also stated that the medication was delivered after the resident had already been discharged home, and the resident did not receive the second treatment as ordered. Facility policy requires that medications be administered as prescribed and within a specified time frame. In this case, the failure to have the medication available and to administer it as ordered resulted in the resident not completing the prescribed treatment regimen. The deficiency was identified through interviews, record reviews, and a review of facility policy, which confirmed that the medication administration did not align with physician orders or facility guidelines.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering prescribed medications as ordered. On one occasion, amlodipine besylate, a medication used to manage blood pressure, was administered to the resident despite the resident's blood pressure being below the parameters specified in the physician's order. The medication was given when the systolic blood pressure was 108, which was below the hold parameter of 120, and there was no documentation explaining the rationale for administering the medication outside of these parameters. Additionally, on another occasion, the resident did not receive a total of 14 prescribed medications at the scheduled administration time. The medications missed included treatments for blood pressure, seizure management, supplements, and other chronic conditions. The Medication Administration Record (MAR) for that day showed that the medications were not signed off as given, and there was no documentation to indicate the reason for the omission, such as resident refusal or difficulty swallowing, nor was there evidence that the physician was notified of the missed doses. The resident involved had a complex medical history, including vascular dementia, hyperlipidemia, hypertensive heart disease, seizures, and hemiplegia following a cerebral infarction. The facility's policy required medications to be administered as prescribed and within a specific time frame, with documentation for any deviations. The lack of documentation and failure to follow physician orders led to the identified deficiency.
Failure to Administer Medications as Ordered and Provide Appropriate Supplies
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for two residents. For one resident with diagnoses including nontraumatic intracerebral hemorrhage, diabetes mellitus type 2, and glaucoma, medications were not administered at the times ordered by the physician. Specifically, eye drops prescribed for glaucoma were given several hours after the scheduled administration times on multiple occasions. The facility's own policies required medications to be administered as ordered, and the Director of Nursing confirmed that these delays constituted a treatment delay and a medication administration error. Additionally, the same resident, who was frequently incontinent and required maximal assistance, was not provided with the correct size of incontinent briefs as requested. The resident reported discomfort and was told by staff that the appropriate size was not available, leading the resident's family member to bring personal supplies. Facility documentation confirmed that the correct size was not available at the time of need, and the Director of Nursing acknowledged that care supplies should be readily available to prevent discomfort and potential complications. For another resident with cellulitis, bladder cancer, and heart failure, the facility failed to notify the physician when the resident did not have a peripheral IV catheter in place, resulting in missed doses of prescribed intravenous antibiotics. Progress notes and medication administration records showed that the resident went without IV access and missed scheduled doses, with no documentation of physician notification. The Infection Preventionist and Director of Nursing both confirmed that the lack of notification and missed medication doses disrupted antibiotic therapy, as outlined in facility policy.
Significant Medication Administration Errors Involving Two Residents
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration by facility staff. One resident, admitted with diagnoses including nontraumatic intracerebral hemorrhage, diabetes mellitus type 2, and glaucoma, had a physician's order for a Bisacodyl rectal suppository to be administered rectally every 12 hours as needed for constipation. However, the suppository was inserted into the vagina instead of the rectum, as confirmed by the resident and documented in the change of condition form. The Director of Nursing acknowledged that this constituted a medication error and noted the potential for delayed treatment and pain. Another resident, admitted with cellulitis of the lower extremity, malignant neoplasm of the bladder, and heart failure, was prescribed a 14-day course of Ertapenem Sodium Injection Solution to be administered intravenously each morning for cellulitis. Review of the Medication Administration Record revealed that on two occasions, there were no staff initials to indicate that the antibiotic was administered as ordered. The Infection Preventionist confirmed the importance of completing the full course of antibiotics and acknowledged that the missed doses represented a failure to follow the physician's order. Facility policies reviewed indicated that medications must be administered in accordance with prescriber orders and professional standards, and specifically addressed the importance of correct route and completion of medication administration. The observed failures in both cases were not in accordance with these policies, resulting in significant medication errors for both residents.
Failure to Develop Comprehensive Care Plan for Resident with JP Drains
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with two right abdominal Jackson Pratt (JP) drains. Despite the resident's complex medical history, including cellulitis of the lower extremity, malignant neoplasm of the colon, and heart failure, and the need for maximal assistance with personal hygiene, showers, and lower body dressing, the care plan did not address the presence or management of the JP drains. This omission was identified through observation, interview, and record review, which confirmed that the care plan lacked measurable objectives and timetables related to the JP drains. Interviews with facility staff, including an LVN and the DON, confirmed that the care plan should be resident-centered and include specific goals and interventions for all resident conditions, but the JP drains were not included. The facility's own policies require the development and implementation of person-centered, comprehensive care plans that address each resident's medical, physical, mental, and psychosocial needs. The failure to include the JP drains in the care plan was acknowledged by staff and was found to place the resident at risk for insufficient provision of care and services related to the JP drains.
Failure to Complete Physician-Ordered CBC with Differential
Penalty
Summary
The facility failed to obtain a complete blood count with differential (CBC with differential) as ordered by the physician for a resident admitted with diagnoses including cellulitis of the lower extremity, malignant neoplasm of the colon, and heart failure. The resident was receiving antibiotic therapy for cellulitis, and the care plan included administering medications as ordered. A physician's order was placed for a repeat CBC with differential, but the initial blood sample collected was clotted and unusable. Although the physician was notified and a new order for blood collection was placed, the laboratory did not collect the sample over the weekend, and there was no documentation that the facility followed up with the laboratory after the weekend to ensure the test was completed. Interviews with facility staff confirmed that the repeat CBC with differential was not completed for the resident. The Infection Preventionist acknowledged that there was no record of follow-up with the laboratory after the initial failed collection, and the Director of Nursing stated that staff should have ensured the test was completed regardless of laboratory notification. Review of facility policies indicated that laboratory services ordered by physicians should be completed in a timely manner to meet residents' needs, but this was not followed in this instance.
Failure to Document PIV Catheter Placement and Removal
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with multiple diagnoses, including cellulitis of the lower extremity, malignant neoplasm of the colon, and heart failure. Upon admission, the resident had a right antecubital (AC) peripheral intravenous (PIV) catheter in place, as documented in the admission evaluation. However, subsequent reviews of the resident's progress notes revealed inconsistencies and missing documentation regarding the removal and placement of PIV catheters. Specifically, there was no record indicating when and why the initial right AC PIV catheter was removed, nor was there documentation of when a new left forearm PIV catheter was placed. Interviews with facility staff, including an LVN and the DON, confirmed the absence of required documentation related to PIV catheter procedures. The facility's own policy required detailed recording of catheter insertion and removal, including date, time, site, and condition of the IV site, as well as notification of the physician in case of complications. The lack of documentation was acknowledged by staff and had the potential to result in inaccurate medical interventions for the resident.
Failure to Ensure Functioning Bed Alarms and Adequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents at high risk for falls. One resident, with a history of falls, dementia, muscle weakness, and a recent hip fracture, was repeatedly attempting to get out of bed unassisted. Despite a physician's order and care plan interventions requiring a functioning bed pad alarm and staff supervision, the alarm was not plugged in or functioning at the time the resident attempted to get out of bed. The family-provided companion notified staff multiple times about the resident's attempts to get up, but the assigned LVN did not check the alarm, did not notify the RN, and did not provide additional interventions. The resident subsequently had an unwitnessed fall, resulting in a severe right arm fracture, blunt head trauma, and required hospitalization and surgery. After the fall, the LVN and CNA moved the resident back to bed without waiting for an RN assessment, contrary to facility policy and job descriptions, which require an RN to assess a resident before moving them after a fall. The RN and DON confirmed that this action was not within the LVN's scope of practice and could have contributed to further injury. Interviews with staff and review of facility policies confirmed that the responsibility for fall prevention and supervision remains with facility staff, regardless of the presence of a family-provided companion, who was not medically trained and was not responsible for direct care. A second resident, also at high risk for falls with a history of traumatic brain and bone injuries, was observed with a disconnected bed alarm despite a physician's order and care plan requiring its use. Multiple staff entered the room without checking or ensuring the alarm was functional. The DON acknowledged that the care plan was not implemented and that the pad alarm should be checked for functionality every time staff enter the room. Facility policies reviewed emphasized the need for individualized interventions, adequate supervision, and consistent use of assistive devices to prevent avoidable accidents, all of which were not followed in these cases.
Failure to Notify Physician of Delay in Emergent Transfer After Resident Fall
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify the primary physician regarding a delay in transferring a resident to the hospital after a significant change in condition. The resident, who had a history of hip fracture, dementia, osteoporosis, muscle weakness, and previous falls, sustained a fall resulting in swelling to the forehead, a skin tear to the left arm, swelling to the right upper arm, and a change in mobility status. The physician was initially notified and ordered an emergent transfer via 911, but the resident's family member refused the immediate transfer and requested to wait until arrival at the facility, causing a delay of approximately 30 minutes before 911 was called. During this period, there was no documented evidence that the physician was informed of the family member's refusal or the delay in executing the transfer order. Interviews with staff, including the RN involved and the Director of Nursing, confirmed that the facility's policy required physician notification when there is a refusal of care or a need to significantly alter treatment, such as delaying an emergent transfer. The staff acknowledged that the physician should have been notified of the delay, but this did not occur. Facility policies reviewed indicated that the physician must be informed of accidents resulting in injury, significant changes in treatment, and decisions to transfer or discharge a resident. The failure to notify the physician of the delay in transfer, as required by policy, resulted in a deficiency related to the immediate notification of the resident's physician in situations affecting the resident's health and treatment.
Failure to Timely Report Abuse Allegation to Ombudsman
Penalty
Summary
The facility failed to report an allegation of employee-to-resident abuse to the Ombudsman as required by its abuse policy. A resident with diagnoses including Parkinson's disease, hemiplegia, and hemiparesis, and with intact cognition, reported to a registered nurse that two certified nursing assistants had hit her during hygiene care and repositioning. The incident was documented in the resident's records, and the nurse reported the allegation to the state survey agency and local law enforcement within two hours, but neglected to notify the Ombudsman. The facility's policy and state and federal regulations require that all allegations of abuse be reported to the Ombudsman within two hours by phone and followed by a written report within 24 hours. Interviews with facility staff, including the registered nurse and the director of nursing, confirmed that the Ombudsman was not notified of the abuse allegation as required. The director of nursing, acting as the abuse coordinator, acknowledged that the failure to notify the Ombudsman was a deviation from both facility policy and regulatory requirements. The omission was also confirmed through review of the facility's abuse prohibition and prevention program policy.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's physician when the resident reported numbness and weakness on the right side of her face. The resident, who had diagnoses including chronic respiratory failure, type 2 diabetes, ventilator dependence, and hypertensive heart disease, was cognitively intact and dependent on staff for activities of daily living. On the evening in question, the resident informed a registered nurse (RN) of her symptoms. The RN assessed the resident for signs of stroke, found none, and educated the resident on stroke symptoms, but did not notify the physician. The RN later acknowledged that she should have contacted the physician but failed to do so at the time. The resident continued to experience symptoms over the weekend and reported them again to a different RN, who then notified the physician and arranged for the resident to be transferred to the emergency department, where she was diagnosed with Bell's Palsy. The facility's policy required timely notification of the physician and resident representative in the event of significant changes in a resident's condition. The Assistant Director of Nursing confirmed that the physician should have been notified immediately and that there was a delay in care and treatment.
Medication Left Unattended at Bedside
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) left a resident's medication, specifically polyethylene glycol 3350 powder mixed with water, unattended on the resident's bedside table. The LVN had administered all other scheduled medications but forgot to give the mixed medication, leaving it in the room while stepping away to the nurse station. Upon returning, the LVN realized the medication had not been administered and acknowledged that medications should not be left unattended. This was confirmed during an interview, where the LVN stated that leaving medications unattended could result in other residents taking the medication or the intended resident not receiving it. The resident involved had been admitted with acute respiratory failure, type 2 diabetes mellitus, and benign prostatic hyperplasia, and was prescribed the medication for bowel management. The facility's policy on administering medications required that medications be given safely and timely, following the pour, pass, chart standard of practice. Both the LVN and a registered nurse (RN) interviewed confirmed that the medication should not have been left unattended and that the facility failed to ensure the resident received all scheduled medications before the nurse left the room.
Failure to Complete Fall Risk Assessment Upon Admission
Penalty
Summary
A resident with a history of falls, diabetes mellitus, muscle weakness, and anemia was admitted to the facility. Upon admission, the facility failed to complete a fall risk assessment for this resident, despite the facility's policy requiring such an assessment within 2 to 24 hours of admission. The resident's records, including the Minimum Data Set, indicated a need for moderate to maximal assistance with daily activities and transfers, and documented a history of falls. The care plan, revised over a month after admission, identified the resident as being at risk for recurrent falls and injury due to deconditioning and balance problems. During interviews, both a registered nurse and the Director of Nursing confirmed that the fall risk assessment was not completed upon admission, acknowledging that the assessment is necessary to identify residents at risk and to initiate appropriate fall prevention interventions. The facility's policy on fall management specifically requires a fall risk evaluation for each new admission, and the omission in this case was recognized as a failure to follow established procedures.
Failure to Obtain Weekly Weights After Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to obtain weekly weights for a resident who experienced a significant change in condition, specifically a weight loss of 15 pounds in one week. The resident had been admitted with diagnoses including hypertensive heart disease with heart failure, muscle weakness, and polyneuropathy. The care plan, created and revised after the weight loss, included interventions such as weekly weights and monitoring for changes in condition, but these interventions were not consistently implemented. The resident's weight dropped from 157 lbs. to 142 lbs. within eight days, representing a 9.6% loss. Despite the care plan and interdisciplinary team notes indicating the need for weekly weights, the next documented weight was not obtained until nearly two weeks later. During this period, the resident developed edema in both lower extremities and upper arms, and a subsequent weight measurement showed a significant increase, which was not immediately recorded due to concerns about accuracy. The facility's own policy required weekly weights for new admissions and for residents with significant weight changes, but this was not followed. Interviews with the ADON and DON confirmed that weekly weights were not performed as required for the resident, and both acknowledged that this lapse could have led to a delay in care. The facility's policy and the care plan both specified the need for weekly monitoring, but the failure to obtain and document these weights resulted in a deficiency related to maintaining adequate nutrition and hydration for the resident.
Failure to Provide Timely Laboratory Services for a Resident
Penalty
Summary
The facility failed to provide timely laboratory services for one resident who was admitted with diagnoses including hypertensive heart disease with heart failure, muscle weakness, and polyneuropathy. The resident developed dysuria, and a physician ordered a urinalysis (UA) and culture and sensitivity (C/S) to be completed. The initial urine specimen collected was found to be insufficient, prompting a repeat order for UA and C/S. Although a nurse collected the repeat specimen and placed it in the facility's refrigerator, the laboratory had already made its scheduled pick-up earlier that day. No staff member called the lab to inform them that the specimen was ready, nor did anyone follow up to ensure the specimen was picked up or to obtain the results. The order for the laboratory test subsequently fell off the facility's tracking system, and the resident was discharged without the ordered labs being completed. Interviews with the DON and the nurse involved confirmed that there was no verification of specimen pick-up or follow-up on the test results. The facility's policies required timely completion and reporting of laboratory services, but these procedures were not followed in this instance, resulting in the deficiency.
Failure to Maintain a Clutter-Free, Homelike Environment for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's room was free from clutter, as required to maintain a safe, clean, and homelike environment. During an observation with an LVN, multiple boxes, bags, blankets, and clothing were found cluttering both sides of the room entrance. The items belonged to the resident's roommate. The Director of Nursing confirmed that the resident was cognitively impaired and acknowledged that a reasonable person would not feel comfortable in such a cluttered environment. The resident involved had a history of epilepsy, schizophrenia, and muscle weakness, and was assessed as having severely impaired cognitive functioning. The resident required maximal assistance with lower body dressing and was dependent for eating, personal hygiene, and toilet transfers. The care plan indicated a high risk for falls and injuries, with specific instructions to keep the environment free from obstruction. Despite these documented needs, the room remained cluttered, contrary to the facility's policy and procedure for maintaining a homelike environment.
Failure to Administer Muscle Spasm Medication as Ordered
Penalty
Summary
A resident with diagnoses including neuropathy, malignant melanoma, hypothyroidism, and muscle weakness was admitted with intact cognitive function and the capacity to make decisions. The resident had a physician's order for Baclofen 5 mg three times daily for muscle spasms, which was discontinued, and a new order for Cyclobenzaprine HCl 10 mg every 8 hours as needed for muscle spasms was issued. On the day following the medication change, the resident reported experiencing muscle spasms and discomfort, stating he had not received his muscle spasm medication since the previous night. The LVN present was unaware of the new Cyclobenzaprine order and did not review the complete order summary, resulting in the resident not receiving the prescribed medication when requested. The medication administration record confirmed that Cyclobenzaprine was not administered until several hours after the resident's complaint. The DON acknowledged that the facility failed to administer medications and treatments as ordered by the physician, attributing the delay to the LVN's failure to review the updated orders. Facility policy required medications to be administered as prescribed and in accordance with written orders, which was not followed in this instance.
Failure to Post Isolation Sign for Resident on Contact Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not posting an isolation sign near the room of a resident who was under contact precautions for a multidrug-resistant E. coli urinary tract infection. The resident's care plan and physician's orders specified the need for contact isolation and the posting of a precaution sign, in accordance with facility policy. However, during observation, although an isolation caddy with PPE was present on the door, there was no sign indicating the type of precautions or required PPE for entry. Interviews with facility staff, including an LVN, the Infection Preventionist Assistant, and the Director of Nursing, confirmed that an isolation sign should have been posted to alert staff and visitors of the necessary precautions. The facility's own policy also required such signage to inform staff of the type of precaution required. The absence of the sign was acknowledged by staff as a failure to follow protocol, which could have led to improper use of PPE and increased risk of infection transmission.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in care. Resident 29, who was admitted with chronic obstructive pulmonary disease, asthma, MRSA infection, type 2 diabetes mellitus with hyperglycemia, and cellulitis, was observed using a CPAP machine without an order, assessment, or care plan in place. Additionally, there was no care plan for the administration of Humulin R, a hypoglycemic medication, for Resident 29, despite the resident being on a high-risk drug class. The lack of care plans for these treatments meant that staff were not guided on the safe use and monitoring of these interventions, potentially compromising the resident's care. Resident 73, who was admitted with a flaccid neuropathic bladder, chronic viral hepatitis C, and acute respiratory failure, was prescribed Cephalexin, Ciclopirox, and Lotrimin AF cream. However, there were no care plans developed for these medications, which are crucial for monitoring side effects and ensuring safe administration. The absence of care plans for these medications indicated a failure to communicate the necessary interventions and goals to the healthcare team, which could affect the resident's treatment outcomes. Resident 52, diagnosed with type 2 diabetes mellitus with hyperglycemia and dysphagia, was receiving Insulin NPH without a corresponding care plan. This oversight meant that the staff lacked guidance on the safe administration and monitoring of the insulin, which is critical for managing the resident's diabetes. Additionally, Resident 97, who expressed a preference for only female CNAs due to fear of male caregivers, did not have this preference documented in a care plan. This lack of documentation led to a failure in respecting the resident's preferences, which could negatively impact their psychosocial well-being.
Plan Of Correction
Social Services provided a list of residents with known preferences for a specified gender of caregivers on 3/18/2025. Copies of the audits were provided to the DON for further review and analysis. A total of 65 residents' records were analyzed. The IDT developed and implemented person-centered care plans for 9 of 65 residents who required person-centered care plans for use of insulin, CPAP therapy, or who had expressed preferences for a specified gender of certified nurse assistant. Residents identified without interventions specific to CPAP, use of insulin, and preferences for specified caregivers. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The Director of Nursing/designee will re-educate the licensed nurses and IDT on or before 3/20/2025, re: the facility policy and procedure "Develop - Implement Comprehensive Care Plans," to ensure the development of a person-centered care plan is completed with person-specific interventions to address use of CPAP machines, use of insulin, and known preference for a specific gender of certified nurse aides. The interdisciplinary team will review the care plans of newly admitted residents and residents with physician order changes from the prior business day during the clinical meeting to ensure care planning for the preference for the use of insulin, CPAP machines, and known preferences for gender-specific certified nurse aides are developed and implemented to ensure staff have guidelines to care for residents. D. How the facility plans to monitor its performance to make sure solutions are sustained; The interdisciplinary team, led by the MDS Coordinator, completes a discipline-specific assessment of each resident at the time of admission to ensure person-centered care planning is present; to provide appropriate monitoring interventions. Care plans will be monitored and updated to reflect current interventions on admission, within 21 days, quarterly, annually, with significant change, as indicated. The MDS Coordinator/designee will report trends identified in the interdisciplinary team audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025.
Failure to Rotate Injection Sites and Administer Medication as Ordered
Penalty
Summary
The facility's licensed nursing staff failed to adhere to professional standards by not rotating the subcutaneous administration sites for insulin and heparin for three residents. Resident 65, who has type 2 diabetes mellitus and requires insulin, had multiple instances where insulin was administered in the same area, contrary to the physician's orders and facility policy. This practice was confirmed by both the Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the failure to rotate injection sites could lead to adverse effects such as bruising and skin conditions. Similarly, Resident 29, who was on heparin for deep vein thrombosis prophylaxis and insulin for diabetes, also experienced repeated administration in the same site. The Registered Nurse and Director of Nursing both noted the importance of rotating injection sites to prevent skin damage and ensure proper medication absorption. Despite the facility's policy and manufacturer's guidelines, the staff did not comply with the required rotation of injection sites. Additionally, Resident 52, who has type 2 diabetes and cognitive impairments, received insulin injections repeatedly in the same area. The Registered Nurse and Director of Nursing confirmed the oversight, emphasizing the risk of skin damage and impaired medication absorption. Furthermore, Resident 197 did not receive three doses of levothyroxine as ordered, which could affect thyroid function. The Director of Nursing acknowledged this as a medication error, highlighting the need for adherence to prescribed medication schedules.
Plan Of Correction
F 658 The DSD/designee will complete weekly audits of residents receiving subcutaneous injections to ensure licensed nurses are rotating injection sites routinely to ensure residents do not experience tissue damage to the extent possible. The DSD/designee will run an injection administration audit through PCC weekly to audit. Concerns identified will be reported to the Director of Nursing for further review, analysis, and follow-up. The Director of Staff Development will re-educate licensed nurses on the facility policy and procedure, "Physician Orders," with emphasis on following physician orders including ordered time and frequency of administration on or before 3/21/2025. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Consultant Pharmacist monitors licensed nurses' proper administration of medication during routine facility audits and reports the findings to the QAA Committee, at a minimum quarterly for the purpose of process improvement. The Director of Nursing will monitor the DSD audits of resident subcutaneous injection sites by licensed nurses to ensure sites are rotated to mitigate tissue damage to the extent possible and to identify continued compliance or the need for further education or progressive disciplinary action through use of the injection administration audit on PCC. The Director of Medical Records/designee will audit the administration times of residents with Levothyroxine orders to ensure residents receive medication during acceptable timeframe for medication administration, monthly. Results of the medication administration audit will be given to the Director of Nursing for further review, analysis, and follow-up as indicated. Compliance concerns identified will be corrected immediately and reported to the Director of Nursing for further corrective action as indicated. Trends identified in the injection site rotation audits will be reported by the Director of Staff Development to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date 3/25/2025 F 658 F 658 F 658 F 658 F 658 F 658 F677 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: CNA 1 received one-to-one re-education regarding grooming and personal hygiene including cleaning the overbed table before and after placing washcloths onto it, hand hygiene prior to and following providing grooming assistance to the residents, and removing gloves prior to leaving the room to reduce the potential adversely affecting residents' psychosocial well-being. Certified Nurse Assistants are performing hand hygiene prior to donning and following doffing of gloves. Resident 65 is receiving grooming care in a manner that promotes his psychosocial well-being. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: All residents are potentially affected by the facility practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The DSD/designee will re-educate nursing staff on the facility's policy "Activity of Daily Living" with emphasis on hand hygiene prior to and after.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and provide adequate supervision to prevent accidents for several residents. For one resident, two tubes of triamcinolone acetonide cream were left unattended at the bedside, despite the resident not having an order for the medication and not being evaluated for self-administration. This oversight was observed by multiple staff members, including a CNA and an LVN, who acknowledged the error but did not take immediate action to rectify it. The presence of the cream posed a risk of self-administration and potential adverse reactions. Another resident, who was at high risk for falls, had a floor alarm that was not activated, leaving the resident unattended and vulnerable to falls. The RN responsible for the resident admitted to turning off the alarm and leaving the resident without supervision, which was against the facility's policy. This lapse in supervision could have resulted in a fall and subsequent injury to the resident. Additionally, the facility failed to ensure that fall mats were free from obstructions for several residents. Observations revealed that furniture and medical equipment were placed on top of fall mats, increasing the risk of injury if a resident were to fall. Furthermore, the facility did not complete post-fall monitoring for a resident as per policy, missing several shifts of documentation and monitoring after a fall incident. These deficiencies highlight a lack of adherence to safety protocols and procedures designed to protect residents from avoidable accidents.
Plan Of Correction
B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents with the use of pad alarms, landing mats, and medications left unattended at the bedside are potentially affected by the facility practice. The Director of Nursing/designee audited the rooms of residents who use alarms and landing mats to ensure alarms were turned to the on position when the resident is using the device and to ensure furniture or other items are not obstructing the landing strip on 2/27/2025. Five other patients were affected, and the furniture was moved so that it was not obstructing the mat on 2/27/2025. The Charge Nurse audited all resident rooms to identify residents with unattended medications at the bedside on 2/24/2025. No other affected residents were found. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Staff Development will re-educate the nursing staff on 3/18/25 the facility policy and procedure, "Accidents and Fall Management," with emphasis on the requirements to: 1. Medications should not be left at the bedside in the absence of residents assessed and approved for self-administration of medications. 2. Floor pad alarms should be in the on position when the resident is in bed. 3. Liquids on the floor are everyone's responsibility and should be cleaned by the appropriate personnel when seen, and a wet floor sign should be placed over the wet area. 4. Furniture should be clear of fall mats to reduce the potential for the furniture to obstruct a resident's fall. 5. Post-fall assessments should be completed following each episode of falling for residents. The Director of Staff Development will orient new nursing personnel, at the time of hire and annually, on the facility policy and procedure, "Accident Management," with emphasis on resident monitoring, activating alarms, not leaving medications at bedside, and attending to spills on the floor for safety. The Registered Nurse Supervisors will complete walking rounds during their assigned shifts at the beginning of their shifts to ensure resident interventions to reduce falls and/or reduce injury with falling are implemented, including ensuring alarms are activated and that furniture or other obstructions are not blocking the mats. They will also identify if residents have medications at their bedside. The Administrator revised the Management Team's rounding tool to include identification of medications at the bedside and unsafe hazards, including fluid on the floor, alarms not activated, landing strips with obstructions, and medications at the bedside. Management team consists of all department heads with room rounds. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Management Team will monitor their assigned resident rooms five times weekly to ensure compliance with medications, landing mats, alarms, and fluid spills for the safety of all residents. The DSD will complete safety rounds daily during routinely scheduled work hours to ensure resident safety interventions are implemented, including proper functionality of pad alarms, placement of landing mats, and no spills on the floors. Concerns identified will be corrected at the time of observation and reported to the Director of Nursing. The Director of Nursing will monitor the licensed nurses and certified nursing assistants' performance through direct observation, Department Manager audits, and DSD rounds; and provide re-education or progressive disciplinary action as indicated. The Director of Medical Records/Designee will audit nurses' follow-up charting daily after a fall. The Administrator will conduct routine rounds each day during routinely scheduled work hours to ensure residents are supervised and safety interventions are activated, without obstructions, and floor signs are placed where spills have been cleaned. The DON/designee will report trends identified in resident care plans, assessment, supervision, and safety intervention observations and audits to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025. F 689 F 689 F 689 F 689 F 690 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 83's catheter drainage bag was adjusted to ensure the drainage tube did not have a kink or a loop to reduce the potential for development of urinary tract infection on 2/26/2025. Resident 53's catheter drainage bag was adjusted to ensure the drainage tube did not have a kink or loop to reduce the potential for development of urinary tract infection on 2/26/2025. The DON audited Resident 83 and Resident 53's changes in condition from 2/1/2025 through 2/26/2025 to identify if either resident developed a urinary tract infection. Neither resident experienced a UTI in the month of February.
Failure to Ensure Safe Use of CPAP Machine
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident using a home CPAP machine. The resident, who was admitted with diagnoses including COPD, asthma, and obstructive sleep apnea, did not have a physician's order for the use of the CPAP machine in the facility. Additionally, there was no assessment of the CPAP machine's integrity, no monitoring of the resident's respiratory condition or response to therapy, and no care plan that included interventions for CPAP therapy. Observations and interviews revealed that the resident's CPAP machine and mask had not been checked or cleaned according to the manufacturer's guidelines, which included daily cleaning of the mask and tubing. The resident confirmed that the mask and tubing had not been changed for several weeks. The facility's staff, including a registered nurse and a respiratory therapist, acknowledged the lack of a physician's order, assessment, and care plan for the CPAP machine, as well as the failure to clean the equipment as required. The Director of Nursing and the Infection Preventionist also confirmed these deficiencies, emphasizing the importance of having a physician's order, a care plan, and proper cleaning procedures to prevent respiratory infections. The facility's policies and procedures, as well as the CPAP machine's user manual, outlined the necessary steps for safe and effective use of the CPAP machine, which were not followed in this case.
Plan Of Correction
A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident 29's physician assessed the use of the CPAP machine and provided orders for its use and monitoring. The licensed nurse transcribed the physician order for the use and monitoring of Resident 29's CPAP machine on 2/26/2025. The Director of Maintenance evaluated the CPAP machine's safety and integrity on 2/26/2025. The licensed staff are monitoring Resident 29's use of CPAP machine daily and documenting the monitoring in the treatment administration record. The CPAP machine is cleaned routinely per manufacturer's guidelines by the Licensed Vocational Nurses. The IDT developed and initiated a care plan for the use of Resident 29's CPAP including interventions for assessment and monitoring of Resident 29's respiratory status and care of the CPAP machine on 2/26/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents using home CPAP machines are potentially affected by the facility practice. The Assistant Director of Nursing audited all residents who use CPAP machines. A total of 3 residents use CPAP machines. 0 of 3 residents CPAP machines were brought from home. No other residents identified affected by the facility practice. The IDT audited care plans of residents who use a CPAP machine for respiratory conditions to ensure interventions including an assessment, physician order, monitoring and cleaning were present on 2/26/2025. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The Director of Nursing/designee will re-educate the nursing staff on or before 3/21/2025, re: the facility policy and procedures, Care Planning, with emphasis on residents with CPAP therapy must have person-centered interventions based on the assessment including evaluation of the safety and integrity of a CPAP machine, when brought from home, No Smoking sign at the resident's door, tubing and mask materials, routine evaluation of respiratory condition through pulse oximeter and routine cleaning per manufacturers guidelines for the CPAP machine. The Interdisciplinary Team will evaluate newly admitted residents for to identify residents with CPAP therapy to ensure the completion of an assessment, physician order and comprehensive person-centered care plan with interventions for CPAP therapy, routine cleaning of the mask and replacement of the tubing, and cleaning of the CPAP machine. Charge nurses will complete routine pulse oximetry each shift of residents with CPAP machines. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Infection Prevention Nurse/designee will monitor residents who use CPAP therapy to ensure cleanliness of the mask, tubing and machine per manufacturer's guidelines to reduce the risk of residents developing respiratory infection. The Charge Nurse will monitor the residents' respiratory health, assess the resident's pulse oximetry and document in the medication administration record each shift. Concerns identified will be corrected at the time of observation and reported to the Director of Nursing. The Director of Nursing will monitor the licensed nurses' performance through observation and IPN reports; and provide re-education or progressive disciplinary action as indicated. The DON/designee will report trends identified in CPAP therapy to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement changes to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 --- F697 Pain Management CFR(s): 483.25(k) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The licensed nurse completed a pain assessment of Resident 65 to ensure current pain management program is effective on 2/24/2025. CNA 1 received 1:1 re-education on the facility procedure to report resident complaints of pain to the charge nurse for further evaluation on 2/24/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents cared for by certified nurse assistant 1 are potentially affected. The Charge Nurse interviewed residents cared for by CNA 1 on 2/24/2025 and completed a pain assessment in the medication administration record to identify residents who had unreported complaints of pain. No other residents had complaints of pain that were not conveyed to the charge nurse. No other residents were affected by the facility practice.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to accurately account for controlled medications, affecting two residents. For Resident 87, a discrepancy was found in the Drug Control Receipt Record for clonazepam, where the physical inventory contained one less dose than recorded. LVN 4 admitted to administering the missing dose but failed to document it due to being distracted by other tasks. Similarly, for Resident 93, a discrepancy was noted with lorazepam, where the medication card contained one less dose than recorded. LVN 3 acknowledged administering the dose but forgot to sign it out, highlighting a lapse in maintaining accurate records for controlled substances. In another incident, the facility failed to administer alprazolam to a resident who requested it for anxiety. Resident 347, who was newly admitted with a diagnosis of generalized anxiety, requested the medication at 6 a.m. but did not receive it until after 10 a.m. LVN 6 and LVN 7 both failed to ensure the medication was administered promptly, resulting in a delay that could have exacerbated the resident's anxiety. The facility's policy for timely administration of as-needed medications was not followed, as confirmed by the Director of Nursing. Additionally, the facility did not administer three doses of levothyroxine to Resident 197 as ordered. The resident, diagnosed with hypothyroidism, reported not receiving the medication consistently since admission. A review of the Medication Administration Record revealed that three doses were not administered, which could affect the resident's thyroid function. LVN 1 confirmed the discrepancy and acknowledged the importance of administering medications as ordered to manage the resident's condition effectively.
Plan Of Correction
Request these medications. Resident 197 discharged on 3/4/25. Resident's MD declined to have thyroid hormone level checked after the discovery of missed doses. MD was notified about the missed doses on 2/28/25 with no new orders. Licensed Nurses are administering Resident 197's levothyroxine in accordance with the physician order. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents with controlled substances are potentially affected, and residents not receiving medications as ordered by the physician are potentially affected. The Assistant Director of Nursing/designee completed a controlled substance count of controlled medications at the time of the survey on 2/25/2025 to identify potentially affected residents. All controlled substances were compliant during reconciliation, and the deficient practice was isolated to LVN 3 and LVN 4. All residents are potentially affected by not receiving their as-needed medications when requested. Request these medications. Resident 197 discharged on 3/4/25. Resident's MD declined to have thyroid hormone level checked after the discovery of missed doses. MD was notified about the missed doses on 2/28/25 with no new orders. Licensed Nurses are administering Resident 197's levothyroxine in accordance with the physician order. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur; License Nurse 7 was re-educated by the Director of Nursing/designee on 2/25/2025, on the facility policy and procedure, "Medication Administration," with emphasis on administering as-needed medications when residents request such medications. LVN 3 and LVN 4 were re-educated by the Director of Nursing/designee on 2/25/2025 on the facility policy and procedure "Administering Medications," with emphasis on the standard of practice pour, pass, chart to ensure medications including controlled substances are signed, reconciled on the narcotic log and medication administration record when the medication is administered. The DSD, as part of the facility's employee orientation, will educate licensed nurses regarding the facility policy and procedure for medication administration, including evaluation of the nurse's competency to pass and reconcile controlled medications, administer medications per physician order, and prompt administration of as-needed medications when residents request the need for such medications. The Director of Staff Development completed a medication pass observation skill competency of LVN 3, 4, 6, & 7 on 3/21/2025. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Director of Staff Development is responsible for monitoring licensed and certified nurse assistant staff competency during new hire orientation, annually, and as needed when a variance to standard is identified regarding the facility's "Medication Administration" policy and procedure. Competency-related concerns identified by the DSD will be reported to the Director of Nursing for further review and instruction as indicated. The Consultant Pharmacist will conduct random medication pass observation audits of licensed nurses to ensure medication administration practices are consistent with the standard of practice and facility policy and procedure once per month. Results of the pharmacist audits will be provided to the Director of Nursing and reported to the QAA Committee at a minimum, quarterly, for the purpose of process improvement. The Director of Nursing/designee will report significant findings identified in the medication administration skill competency audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 F 755
Failure to Respond to Pharmacist's Recommendations on PRN Medications
Penalty
Summary
The facility failed to respond to the consultant pharmacist's recommendations regarding the medication regimens of a resident, identified as Resident 101. The pharmacist recommended limiting the duration of PRN lorazepam to 14 days or defining a specific length of therapy, as well as defining the length of therapy for PRN guaifenesin oral liquid. These recommendations were made on 11/30/2024 and 12/31/2024, respectively. However, the facility did not act upon these recommendations, as evidenced by the lack of new orders or documented responses to the pharmacist's suggestions. Resident 101, who was admitted with an anxiety disorder, was prescribed lorazepam and guaifenesin without defined durations, contrary to the facility's policy. The Director of Nursing acknowledged the failure to limit the duration of these PRN medications, which increased the risk of the resident receiving them inappropriately. The facility's policy required the attending physician to address the pharmacist's recommendations by their next scheduled visit, but this was not adhered to, leading to the deficiency.
Plan Of Correction
F756 Drug Regimen Review CFR(s): 483.45(c)(1) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The licensed nurse clarified Resident 101's use of Lorazepam PRN and the consultant pharmacist's recommendation from 11/24/2024 on 2/24/2025. Resident 101's use of guaifenesin oral liquid was discontinued on 2/27/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents with consultant pharmacist recommendations that have not been responded to are potentially affected by the facility practice. The Director of Nursing requested a consultant pharmacist report on 2/28/2025 of recommendations that have not been responded to for the dates 11/1/2024 through 2/28/2025 to ensure the residents' physicians were contacted and a response was received. The consultant pharmacist provided a list of 0 residents recommendations requiring responses. All consultant pharmacist recommendations were completed. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Nursing revised the facility system for responding to the consultant pharmacist recommendations and filing the MRR in the resident record when an MRR is completed by the consultant pharmacist. The Director of Nursing receives and reviews the pharmacy recommendations from the pharmacist monthly. A copy of the MRR is maintained by month in the DON office. The Nurse Supervisor will receive a copy of the recommendations for timely completion. When completed, the nurse supervisor will file the MRR in the resident's record and provide a copy to the Director of Nursing for review. The Director of Nursing/designee will re-educate the licensed staff on or before 3/21/2025 on the facility policy and revised procedure, "Drug Regimen Review," emphasizing timely completion and filing in the resident's medical record. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Consultant Pharmacist completes medication regimen reviews monthly and provides a list of recommendations to the Director of Nursing. Recommendations from the prior month that remain outstanding are escalated in the report to the Director of Nursing for immediate completion. The Director of Nursing will monitor the completion of the MRR from the date of delivery until the recommendations are completed, including verification of required documentation. The Consultant Pharmacist will report trends identified in timely completion and filing of the MRRs to the Quality Assurance committee during the quarterly QA&A meeting for the purpose of process improvement and to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025. F757 Drug Regimen is free from Unnecessary Drugs. CFR(s): 483.45(d)(1)-(6) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 101's use of guaifenesin oral liquid was discontinued on 2/27/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents receiving PRN medication without a duration, for a temporary condition such as a cough, are potentially affected by the facility practice. The Director of Medical Records generated an audit of all residents receiving guaifenesin oral liquid to identify residents whose medication does not have a stop date and are potentially affected by the facility practice. A copy of the audit was provided to the Director of Nursing on 2/27/2025 for further review and analysis.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Desert Canyon Post Acute, Llc | 0.9 mi | ★★★★★ | 43 | 0 |
| Mirage Post Acute | 0.9 mi | ★★★★★ | 73 | 0 |
| Antelope Valley Care Center | 1.1 mi | ★★★★★ | 21 | 0 |
| Mountain View Conv Hosp | 29.9 mi | ★★★★★ | 39 | 0 |
| Santa Clarita Post-acute Care Center | 29.9 mi | ★★★★★ | 21 | 0 |
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