The Gardens Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Northridge, California.
- Location
- 17650 Devonshire Street, Northridge, California 91325
- CMS Provider Number
- 555791
- Inspections on file
- 48
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Gardens Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple health conditions did not receive their prescribed morning medications, which were left unattended on a meal tray in the hallway. Nursing staff signed the MAR indicating the medications were administered, despite not observing the resident take them. Facility policy required staff to witness medication ingestion and accurately document administration, which was not followed in this instance.
A resident with an indwelling catheter did not receive or have documented catheter care as ordered by the physician on several shifts, and two residents identified as candidates for bowel and bladder retraining did not have such programs initiated due to staff oversight of assessment forms. These deficiencies were confirmed through record review and staff interviews.
The facility did not post actual daily nurse staffing information, including the number of staff and hours worked, in a visible and prominent location as required. Instead, only projected staffing was displayed, and actual staffing data for previous days was not made accessible to residents or visitors, contrary to facility policy.
Two residents with Permacath catheters had their pre- and post-dialysis assessments inaccurately documented by nursing staff, who repeatedly recorded the presence of thrill and bruit—findings not possible with this type of access. Both a registered nurse and the DON confirmed the inaccuracy, and facility policy required precise documentation of dialysis care in the medical record.
A resident with an indwelling urinary catheter, cognitive impairment, and a need for staff assistance was observed to have their urinary catheter bag uncovered, contrary to facility policy and physician orders. Both an RN and the DON confirmed that catheter bags should be covered to maintain dignity, but this was not done for the resident.
A resident with dementia, depression, and a history of falls was found in bed with the call light on the floor and out of reach, despite a care plan requiring it to be accessible. Staff confirmed the call light was not within reach, and facility policy mandates that call lights be accessible to residents at all times.
A resident with intact cognition and multiple medical conditions had an advance directive on file, but facility staff failed to keep a current copy in the active clinical record. Both the SSD and DON confirmed the document was missing from the chart, despite facility policy requiring its presence for staff guidance.
A resident with multiple diagnoses and an indwelling catheter was admitted, but the baseline care plan developed within 48 hours did not address catheter care as required. Staff interviews and record reviews confirmed the omission, despite physician orders for catheter care and facility policy mandating comprehensive baseline care plans for all care areas.
A resident with diabetes, hypertension, and COPD was using a continuous glucose monitoring (CGM) system as ordered by a physician, but staff did not develop or implement a comprehensive, person-centered care plan to address the use and monitoring of the CGM sensor. Interviews with the MDSC and DON confirmed that no care plan with goals or interventions was created, despite facility policy requiring such plans for all residents.
A resident with type 2 diabetes did not receive proper monitoring or support for their continuous glucose monitoring (CGM) system, as staff failed to ensure the availability of sensor patches and did not apply or monitor the device as ordered. The resident independently applied the CGM sensors without staff assessment or documentation, and the admission assessment and care plan were incomplete and did not address the use of the CGM system.
An LVN left a bottle of vitamin C unattended and accessible on top of a medication cart while administering medications to a resident with diabetes, hypertension, and COPD. The bottle was not secured in the cart, making it easily accessible to other residents in the hallway, contrary to facility policy requiring medications to be stored securely and attended by authorized staff.
A resident with multiple medical conditions and cognitive impairment did not receive weekly weight monitoring as ordered by a physician. After an initial weight was recorded, staff failed to document the required weekly weight, missing one week before the next weight entry. Facility leadership confirmed the omission and acknowledged it was not in line with policy or physician orders.
A resident admitted after spinal fusion surgery retained a peripheral IV catheter without a physician order or ongoing need. Nursing staff did not assess or remove the IV upon admission, and facility records lacked documentation or indication for its use, contrary to facility policy requiring physician orders for IV therapy.
A resident with an order for continuous oxygen via nasal cannula was found with their oxygen tubing on the floor and the cannula not attached, contrary to physician orders and facility policy. An LVN confirmed the tubing was contaminated, and the DON acknowledged staff are required to follow oxygen administration orders.
Surveyors found that medications were disposed of in a manner that left them retrievable and that three medications were not properly documented with witness signatures on the Medication Disposition Record/Pass Log. Both a nurse and the DON confirmed that facility policy requiring non-retrievable disposal and dual nurse verification was not followed.
A resident with multiple medical conditions, who was dependent on staff for most ADLs but cognitively intact, had a baked custard left at the bedside for longer than four hours after lunch. Facility staff and dietary policy confirmed that leftover food should be removed within four hours, but this was not done, resulting in improper food handling and sanitation practices.
A resident with dementia and impaired cognition was made to sign her own consent forms for citalopram, influenza, and COVID-19 vaccines, despite lacking the capacity to make medical decisions. The facility failed to involve the Responsible Party (RP) as required by policy, placing the resident at risk. Staff interviews confirmed the oversight and acknowledged the need for RP involvement.
A resident with dementia and high fall risk was not reassessed for elopement risk after triggering exit alarms and wandering. The resident exited the facility without assistance, resulting in a fall and injuries. The facility failed to implement necessary safety measures, contributing to the incident.
A resident's medical records were incomplete due to the facility's failure to document physician orders for surgical wound treatment and urinary catheter drainage bag changes before performing these procedures. The resident, admitted with a spinal fusion, muscle weakness, and hypertension, had an indwelling catheter and a surgical wound. Despite these conditions, treatments were administered without documented orders, leading to inaccuracies in the clinical record. The facility's policies required immediate documentation of verbal orders, but delays were noted, potentially resulting in missed orders.
Two residents in the facility had incomplete care plans, leading to deficiencies in their care. One resident's care plan lacked specified frequency for neuro checks after an unwitnessed fall, while another resident's care plan did not include details about their urinary catheter care. These omissions were confirmed by staff and did not align with the facility's policy on comprehensive care plans.
A resident with an indwelling urinary catheter was not provided proper care as the catheter was not secured to the thigh, contrary to the care plan and facility policy. This oversight was observed during a survey, with the DON acknowledging the risk of dislodgement and infection due to improper securing.
A resident on enhanced barrier precautions was at risk due to a breach in infection control procedures by an RN. The RN failed to change gloves after touching unclean surfaces while performing wound treatment and changing a urinary catheter drainage bag. The facility's infection prevention policies were not adhered to, as confirmed by the DON.
The facility failed to implement comprehensive care plans for residents using psychotropic and anticoagulant medications, side rails, and urinary catheters. This lack of care plans led to unmonitored medication side effects, increased risk of falls, and potential health complications. The ADON and MDSC acknowledged these deficiencies, which were contrary to the facility's policies requiring person-centered care plans.
The facility failed to rotate injection sites for insulin administration for three residents, leading to potential adverse effects. Despite guidelines from insulin manufacturers, repeated injections were given in the same areas, risking complications such as lipodystrophy and poor medication absorption. The ADON confirmed the lack of site rotation for insulin and heparin injections.
The facility failed to properly document and reconcile controlled medications, with missing entries on audit forms for Medication Cart 2. Additionally, a resident did not receive their prescribed cholecalciferol oral liquid due to its unavailability in the medication cart. The facility's policy required timely reordering of medications, which was not followed, leading to a lapse in medication management.
The facility failed to ensure that the drug regimen for two residents was free from unnecessary medications. One resident's order for apixaban lacked a specific medical condition, while another resident receiving heparin was not monitored for adverse effects. These omissions were identified by the MDS Coordinator and the ADON, who confirmed that the facility's policy requiring specific clinical conditions for medication orders and monitoring for adverse effects was not followed.
The facility failed to manage and monitor psychotropic medication regimens for several residents, leading to deficiencies in their care. One resident received lorazepam without a 14-day limit or specific behavior monitoring, while another was given buspirone without documented behavior monitoring. Additionally, residents on quetiapine and citalopram lacked appropriate physician's orders for monitoring target behaviors and adverse effects, risking unnecessary medication use and adverse effects.
The facility failed to rotate injection sites for insulin and heparin in three residents, leading to potential adverse effects. The ADON confirmed repeated injections in the same areas, contrary to guidelines and facility policy.
The facility failed to ensure kitchen staff followed dress code policies, leading to potential cross-contamination. Observations revealed unlabeled and improperly stored food items, including moldy produce, and unsanitary kitchen conditions with grease and debris build-up. Staff acknowledged the risks of foodborne illnesses due to these deficiencies.
A LTC facility failed to maintain an effective infection control program, as evidenced by an LVN not sanitizing a blood pressure cuff between residents, not wearing appropriate PPE for a resident under enhanced precautions, and failing to change a BIPAP mask weekly. Additionally, mechanical lift slings were reused without washing, and nasal cannulas were not labeled with change dates, increasing infection risk.
A resident with Alzheimer's and acute kidney failure was found without a privacy cover on their urinary catheter bag, compromising their dignity. The facility's policy requires such covers to enhance residents' well-being. Both a CNA and the ADON acknowledged the oversight.
A facility failed to assist a resident with formulating an Advance Directive (AD) upon admission, as required by policy. The resident, with type 2 diabetes and intact cognition, did not have documented evidence of AD discussion during care conferences. Interviews confirmed the oversight, highlighting the importance of discussing ADs to respect residents' medical care preferences.
A resident at risk for pressure ulcers was found to have their low air loss mattress (LALM) set incorrectly, not according to their weight as per the manufacturer's guidelines. Despite the resident weighing 195 pounds, the LALM was set to a range of 660 to 750 pounds. Facility staff confirmed the importance of setting the LALM to the resident's weight to prevent skin breakdown and discomfort.
A resident without authorization for self-administration of medications was found with multiple medications left unattended in their room. Staff failed to remove these medications despite being aware of the facility's policy against leaving medications at the bedside. The resident, who required assistance with personal care and had no assessment for self-administration, was at risk of accidental ingestion or overuse.
The facility failed to provide proper catheter care for two residents, resulting in potential infection risks. One resident's catheter tubing was kinked, and the bag was on the floor, while another resident's catheter bag was placed on the floor during a transfer. Staff acknowledged these practices increased infection risks, contrary to facility policy.
A resident receiving IV Sodium Chloride for hypercalcemia had their medication bag and tubing unlabeled, contrary to facility policy. This oversight was confirmed by an LVN and the ADON, who noted the risks of administering unlabeled medication. The facility's policy requires medication containers to be changed every 24 hours and administration sets every 72 hours, but without labels, these protocols could not be followed.
Two residents had bed rails installed without proper assessment or informed consent. Despite policies requiring risk assessment and consent, the facility failed to follow these procedures, leading to potential safety risks.
A facility failed to ensure a nurse had the necessary skills for administering medications via a gastrostomy tube (GT). The nurse used a syringe and slow push method instead of the required gravity method, potentially causing discomfort or dislodging the GT. The nurse lacked a skills checklist and had not attended relevant training, highlighting a gap in staff competency assessment.
A facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. A resident did not receive prescribed cholecalciferol and fluticasone due to their unavailability in the medication cart. The ADON confirmed this omission as an error, aligning with the facility's policy on medication errors.
During a survey, a facility was found to have five unpackaged and unlabeled albuterol nebules in a medication cart, which were not stored according to policy. An LVN admitted to not knowing the owner of the nebules and stated they should have been discarded. The DON confirmed that the facility's medication storage policy was not followed, emphasizing the importance of proper labeling to prevent medication errors.
A facility failed to maintain accurate clinical records when an LVN documented the administration of cholecalciferol to a resident, despite not having the medication available. The resident, admitted with gastrostomy status and retention of urine, had a physician's order for daily cholecalciferol via gastrostomy tube. The ADON confirmed the inappropriateness of documenting unadministered medications, as it can cause potential issues for the resident.
The facility failed to properly explain the arbitration agreement to residents, leading to confusion and lack of awareness about their rights to rescind the agreement. Residents and their representatives signed the agreement without understanding its implications, and the Admissions Director did not inform them of the 30-day rescission option.
The facility failed to screen eight visitors and three staff members for COVID-19 during an outbreak, as required by their policy and public health guidelines. Observations and interviews revealed missing temperature entries and unanswered screening questions, with staff acknowledging the lapses in procedure.
The facility failed to accommodate a room change request for a resident with Alzheimer's disease, despite available rooms and complaints from other residents. The request was communicated but not acted upon, potentially impacting the resident's well-being.
Medications Left Unattended and Incorrectly Documented as Administered
Penalty
Summary
A deficiency occurred when a resident, who was moderately impaired in thought process and dependent on staff for activities of daily living, did not receive their prescribed morning medications as required. The resident had diagnoses including hypertension, osteoarthritis, and pulmonary embolism, and was prescribed medications such as Eliquis, multivitamins, Coenzyme Q10, losartan potassium, and metoprolol. On the day of the incident, a medication cup containing five medications was observed left on top of the resident's breakfast tray, which was parked unattended in the hallway. Both a Licensed Vocational Nurse and a Registered Nurse confirmed the presence of the medication cup and stated that the nurse responsible should have observed the resident taking all medications to ensure proper administration. Despite the medications not being administered, the Medication Administration Record (MAR) was signed by the nurse, indicating that the medications had been given. Interviews with nursing staff and the Director of Nursing confirmed that the MAR should not have been signed unless the medications were actually administered and observed to be ingested by the resident. Facility policy also required staff to observe residents after medication administration to ensure the full dose was taken, and to document any partial ingestion. The failure to follow these procedures resulted in a significant medication error for the resident.
Failure to Provide Catheter Care and Bowel/Bladder Retraining
Penalty
Summary
The facility failed to provide proper care and services for a resident with an indwelling catheter by not administering catheter care as ordered by the physician. The resident, who had diagnoses including urinary retention and a history of urinary tract infection (UTI), required catheter care every shift, including cleansing the area and monitoring for signs of infection. Documentation revealed that on three specific shifts, there was no evidence that licensed nurses provided or documented the required catheter care or monitoring for redness, irritation, swelling, or symptoms of UTI. Both the MDS Coordinator and the Director of Nursing confirmed that the care was not documented and acknowledged that licensed nurses are required to implement physician orders and document the care provided. Additionally, the facility did not implement a bowel and bladder retraining program for two residents who were identified as candidates for such a program upon admission. Both residents had assessments indicating they could comprehend and follow instructions and were suitable for retraining programs. However, after the initial 72-hour assessment period, the staff failed to review the Bowel and Bladder Assessment forms when determining the need for retraining, resulting in neither resident being started on a program. Interviews with the MDS Coordinator and a registered nurse confirmed that the assessments were overlooked, and the required programs were not initiated as per facility policy. The facility's policies and procedures required that catheter care be documented in the resident's medical record, including assessment data and the resident's response to care, and that a toileting program be established within four days of admission for eligible residents. In these cases, the required documentation and program initiation did not occur, as confirmed by staff interviews and record reviews.
Failure to Post Actual Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information, including the actual number of staff and hours worked, was posted in a visible and prominent location as required. During an observation and interview with the Director of Staff Development (DSD), it was found that only projected staffing information for the current day was posted at the nursing station, rather than the actual staffing data for previous days. The DSD confirmed that the actual staffing information for the previous two days was not posted. Further interviews revealed that the Director of Nursing (DON) stated that daily staffing information is placed at the nursing station and that residents, families, and visitors could ask staff about the number of nursing personnel providing direct care. However, review of the facility's policy indicated that actual staffing numbers and hours worked for each shift must be posted within two hours of the beginning of each shift in a prominent location. The facility did not follow this policy, resulting in the required information not being readily accessible to residents and visitors.
Inaccurate Dialysis Assessment Documentation for Residents with Permacath Catheters
Penalty
Summary
The facility failed to ensure accurate completion of pre- and post-dialysis assessments for two residents who were dependent on dialysis and had Permacath catheters in place. Both residents had complex medical histories, including type 2 diabetes, muscle weakness, and end-stage renal disease, and were dependent on staff for activities of daily living. Documentation in their medical records repeatedly indicated that a thrill and bruit were present at the dialysis access site, which is not possible with a Permacath catheter. Record reviews showed that for multiple dates, nursing staff checked off the presence of thrill and bruit on both pre- and post-dialysis assessment forms for these residents. During interviews, a registered nurse and the DON confirmed that this documentation was inaccurate, as Permacaths do not produce a thrill or bruit. The facility's policy required accurate documentation of dialysis care, including the use of the Pre/Post Dialysis form, and maintaining this information in the resident's medical record. The inaccurate charting of assessment findings was acknowledged by both the registered nurse and the DON, who stated that licensed nurses should not have documented the presence of thrill and bruit for residents with Permacaths. This failure to accurately assess and document the residents' dialysis access sites resulted in the maintenance of incorrect medical information in the residents' records.
Failure to Cover Urinary Catheter Bag with Privacy Bag
Penalty
Summary
A resident with a history of urinary retention, urinary tract infection, and falls was admitted to the facility and had an indwelling urinary catheter in place. The resident's Minimum Data Set indicated moderately impaired cognitive skills and a need for substantial to moderate staff assistance with activities of daily living, including toileting and hygiene. Physician orders required staff to check the placement of the indwelling catheter every shift. During an observation, it was noted that the resident's urinary catheter bag was not covered with a privacy (dignity) bag, as required by facility policy. Both a registered nurse and the Director of Nursing confirmed that catheter bags are required to be covered to promote resident dignity, and acknowledged that the resident's catheter bag was not covered at the time of observation. The facility's policy on dignity specifically prohibits practices that compromise resident dignity and directs staff to assist residents in keeping urinary catheter bags covered.
Call Light Not Accessible to Resident with High Fall Risk
Penalty
Summary
A deficiency occurred when staff failed to ensure that the call light was within reach of a resident who had been admitted with diagnoses including dementia, depression, and a history of falls. The resident's care plan specifically required that the call light and personal belongings be placed within her reach to minimize fall risk and ensure her ability to request assistance. During an observation, the resident was found lying in bed with the call light on the floor, unable to locate or reach it. The resident attempted to search for the call light but was unsuccessful. Certified Nursing Assistant 1 confirmed during the observation that the call light was not within the resident's reach and acknowledged that it should always be accessible. The Director of Nursing also stated that call lights are required to be accessible to residents at all times. Review of the facility's policy indicated that call lights must be within easy reach of residents while in bed. The failure to follow these procedures resulted in the resident's inability to call for help when needed.
Failure to Maintain Resident's Advance Directive in Clinical Record
Penalty
Summary
Facility staff failed to maintain a current copy of a resident's advance directive in the active clinical record, despite documentation indicating that the resident had executed such a directive. The resident, who had diagnoses including normal pressure hydrocephalus, type 2 diabetes mellitus, and major depressive disorder, was assessed as having intact cognition and the capacity to make decisions. During record review, it was found that while the Advance Directive Acknowledgement Form indicated the existence of an advance directive, the actual document was not present in the resident's chart. Interviews with the Director of Social Services and the Director of Nursing confirmed that the advance directive should have been kept in the resident's active chart to guide staff in honoring the resident's wishes. The facility's policy also required that a copy of any executed advance directive be maintained in the resident's medical record and be readily retrievable by staff. The absence of the advance directive in the clinical record constituted a failure to ensure the resident's wishes regarding medical treatment were accessible to facility staff.
Failure to Address Indwelling Catheter in Baseline Care Plan
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who had an indwelling catheter. Upon review, it was found that the baseline care plan did not address the resident's indwelling catheter, despite the resident having diagnoses including type 2 diabetes mellitus, obstructive uropathy, reflux uropathy, and benign prostatic hyperplasia. The resident required varying levels of assistance for activities of daily living and had a physician's order for catheter care, including cleansing and monitoring for signs of infection every shift. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the baseline care plan was incomplete and did not include interventions for the indwelling catheter. The facility's policy required a baseline care plan to be developed within 48 hours of admission, addressing all care areas and necessary nursing interventions. The omission was acknowledged by staff, who stated that the baseline care plan must be thorough to meet the resident's immediate care needs.
Failure to Develop Care Plan for Resident's Continuous Glucose Monitoring System
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for a resident who was using a continuous glucose monitoring (CGM) system. The resident, admitted with diagnoses including type 2 diabetes mellitus, hypertension, and COPD, had intact cognitive skills and was prescribed hypoglycemic medication. Physician orders specified the application of a CGM sensor every 14 days for continuous blood sugar monitoring. Despite this, there was no care plan created to address the use, monitoring, or management of the CGM sensor. Interviews with the MDS Coordinator and the Director of Nursing confirmed that licensed nurses did not develop a care plan with goals and interventions for the resident's CGM sensor. Both acknowledged that the absence of such a care plan meant there were no documented strategies to ensure the sensor was applied properly or functioning as intended. Review of facility policy indicated that a comprehensive, person-centered care plan with measurable objectives and timeframes should have been developed and implemented for each resident, but this was not done for the resident in question.
Failure to Monitor and Support Resident's Continuous Glucose Monitoring System
Penalty
Summary
The facility failed to provide necessary care and services for a resident with type 2 diabetes by not monitoring the resident's continuous glucose monitoring (CGM) system and not ensuring that CGM sensor patches were available for application as ordered by the physician. Documentation showed that on multiple occasions, the required CGM sensor patches were not available in the facility, and staff did not apply the sensors as ordered. Instead, the resident independently applied the CGM sensor patches every 14 days without staff assistance, despite not having requested self-administration of medication. Licensed staff did not monitor the placement or functionality of the CGM system, and the Director of Nursing was unaware of the resident's use of the CGM sensor until it was observed during the survey. Additionally, the facility did not complete the resident's Admission/Readmission Screen and Baseline Care Plan form accurately upon admission. The assessment was left incomplete and unsigned, and it did not address the resident's use of a CGM system. The lack of a comprehensive, person-centered care plan meant that there were no documented goals or interventions for monitoring the resident's CGM sensor, as required by facility policy. The MDS Coordinator confirmed that the absence of a complete assessment and care plan could result in a lack of necessary care and services for the resident. Interviews with nursing staff revealed that the physician's order for the CGM sensor was received and processed, but no additional order for monitoring the device was obtained. Staff acknowledged that the resident's ability to self-administer the CGM sensor was not properly assessed, and the facility did not ensure the availability of sensor patches. Facility policies reviewed indicated that all services and changes in resident condition should be documented, and that comprehensive, person-centered care plans should be developed and implemented for each resident.
Unattended Medication Bottle Left Accessible on Medication Cart
Penalty
Summary
A Licensed Vocational Nurse (LVN) was observed preparing morning medications for a resident with diagnoses including type 2 diabetes mellitus, hypertension, and COPD. During the medication pass, the LVN removed a bottle of vitamin C from the medication cart, dispensed a tablet, and left the bottle unsecured on top of the cart before entering the resident's room to administer medications. The bottle of vitamin C was left unattended and easily accessible to other residents in the hallway. The LVN later acknowledged leaving the vitamin C bottle outside the medication cart, stating that medications should not be left unattended and accessible to residents. The Director of Nursing confirmed that the bottle should not have been left on the cart, as it allowed unsupervised access to medications. Facility policies reviewed indicated that medications must be stored securely and only accessible to authorized personnel, with medication carts locked or attended at all times.
Missed Weekly Weight Monitoring for Resident
Penalty
Summary
The facility failed to follow a physician's order to conduct weekly weights for a resident who was admitted with diagnoses including type 2 diabetes, muscle weakness, and metabolic encephalopathy. The resident was dependent on staff for activities of daily living and had cognitive impairments, as documented in the admission records and assessments. The physician's order, dated 4/21/2025, specified that the resident's weight should be monitored weekly for 30 days. However, a review of the weight records showed that after an initial weight was recorded on 4/22/2025, the next weight was not documented until 5/4/2025, with no weight recorded on 4/29/2025 as required by the order. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that the weekly weight was missed and acknowledged that this was not acceptable practice. The facility's policy on weighing and measuring residents, last reviewed on 1/20/2025, emphasizes the importance of regular weight monitoring as an indicator of nutritional status. The failure to obtain and document the weekly weight as ordered resulted in a deficiency related to the monitoring of the resident's nutritional status.
Failure to Assess and Remove Unnecessary IV Catheter
Penalty
Summary
The facility failed to provide care and services that meet professional standards of quality by not assessing the continued need for a peripheral intravenous (IV) catheter for a resident who was admitted after spinal fusion surgery. Upon admission, the resident had an IV in place on the back side of her right lower arm, but there was no physician order or indication for IV fluids or medications. The resident expressed that she did not know why the IV had not been removed and found it annoying, though it was not painful. The admission and skin evaluation records did not document the presence of an IV, and the electronic medical record also lacked any order or indication for its use. Nursing staff, including a registered nurse and the Director of Nursing, confirmed that the IV should have been identified and removed upon admission, as there was no ongoing need for it. The facility's policy required physician orders for initiating IV therapy, specifying details such as dose, frequency, duration, and diagnosis, none of which were present for this resident. The failure to remove the unnecessary IV upon admission constituted a lapse in following professional standards and facility policy.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified when a resident who had a physician's order for continuous oxygen at two liters per minute via nasal cannula was observed with their oxygen tubing on the floor and the cannula not attached to their nose. The tubing was found under the resident's body, with one end connected to the oxygen concentrator, and the other end not in use. This observation was confirmed by a Licensed Vocational Nurse, who acknowledged that the tubing was contaminated and not in accordance with professional standards of practice. The resident involved had a history of right femur fracture, aphasia, and urinary tract infection, and was assessed as able to make needs known but unable to make medical decisions. Facility policy required the nasal cannula to be properly placed in the resident's nose and secured, and CDC guidelines indicated that floors can become rapidly contaminated. The Director of Nursing confirmed that staff are required to implement physician orders for oxygen administration and acknowledged the potential for infection if tubing contacts the floor and for desaturation if the cannula is not attached.
Improper Medication Disposal and Incomplete Documentation
Penalty
Summary
The facility failed to ensure proper disposal and documentation of medications in accordance with federal regulations and facility policy. During an observation in the medication room, a pharmaceutical waste bin was found to contain a mixture of unopened and unused medications in their original manufacturer packaging, as well as loose, intact tablets and capsules. The registered nurse present confirmed that medications were disposed of without rendering them non-retrievable, as required by policy, since no liquid was poured over them to prevent retrieval. This left the medications in a form that could be easily accessed and reused. Additionally, a review of the Medication Disposition Record/Pass Log revealed that three disposed medications—Vancomycin oral suspension, Nystatin powder, and Naloxone spray—were not documented with the required verifying signatures of two licensed nurses. Both the registered nurse and the Director of Nursing confirmed that these medications were not logged or witnessed as per policy. The facility's policy requires that all destroyed medications be entered on the disposition form with date, resident's name, medication details, and signatures of witnesses, which was not followed in these instances.
Failure to Remove Leftover Food from Resident Room Within Required Timeframe
Penalty
Summary
The facility failed to ensure proper sanitation and food handling practices when a resident's leftover food was not removed from the bedside after four hours. Specifically, a resident with diagnoses including normal pressure hydrocephalus, type 2 diabetes mellitus, and major depressive disorder, who was cognitively intact but dependent on staff for most activities of daily living, had a baked custard left on the bedside table for an extended period. The resident reported that the custard had been in the room for a couple of days, and staff confirmed it was served during lunch the previous day. Facility policy, as reviewed with the Dietary Supervisor, requires that leftover food not be stored in resident rooms for more than four hours due to the lack of temperature control and the risk of foodborne illness. Observations and interviews with nursing and dietary staff confirmed that the custard was not removed within the required timeframe, and the policy was not followed. The failure to remove the food in a timely manner created a situation where the resident could have consumed contaminated food.
Failure to Obtain Proper Consent for Resident with Impaired Cognition
Penalty
Summary
The facility failed to ensure that the Responsible Party (RP) or Resident Representative (RR) signed consent forms for a resident with a history of dementia and moderately impaired cognition. The resident, who was unable to make medical decisions, was made to sign her own consent forms for the administration of citalopram, an influenza vaccine, and a COVID-19 vaccine. This action was contrary to the facility's policy, which requires a surrogate decision-maker to be identified when a resident lacks the capacity to make informed decisions. The resident's admission record indicated diagnoses including Parkinson's disease, generalized muscle weakness, and a neurocognitive disorder with Lewy bodies. Despite these conditions, the resident signed the consent forms in the presence of a registered nurse, without the involvement of the RP. The facility's policy mandates that informed consent should be obtained from the RP when a resident is determined to lack decision-making capacity, which was not adhered to in this case. Interviews with facility staff, including the Director of Nursing and the Director of Staff Development, revealed that the RP was not notified prior to the administration of the medications and vaccines. The staff acknowledged that the resident did not have the capacity to sign the consent forms and that the RP should have been contacted to provide consent. The facility's failure to follow its own policies and procedures for obtaining informed consent placed the resident at risk for making healthcare decisions without proper understanding or authorization.
Failure to Prevent Resident Elopement and Fall
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident with a history of dementia, high fall risk, and wandering behavior. The resident, admitted on 12/30/2024, had diagnoses including Parkinson's disease, generalized muscle weakness, and neurocognitive disorder with Lewy bodies. Despite being assessed as high risk for falls, the resident was not reassessed for elopement risk after triggering the exit door alarm twice on 12/31/2024 and exhibiting wandering behavior on 1/1/2025. On 1/2/2025, the resident managed to walk two steps outside the facility's exit door without staff assistance or an assistive device, resulting in a fall. The resident sustained injuries, including a comminuted nasal bone fracture and fractures in the right hand, requiring transfer to a general acute care hospital. The facility's failure to reassess the resident's elopement risk and implement appropriate interventions, such as a wander or elopement alarm, contributed to the incident. Interviews with facility staff revealed that the resident was known to wander and had previously set off the exit door alarm. However, there was no documentation of increased monitoring or reassessment for elopement risk. The facility's policies and procedures for safety and supervision were not adequately followed, as the resident's care plan did not include necessary interventions to prevent elopement and ensure safety.
Incomplete Documentation of Physician Orders
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented, leading to deficiencies in the care provided. Specifically, the facility did not document the physician's order for surgical wound treatment in the resident's clinical record before performing the treatment. Additionally, the order to change the resident's indwelling urinary catheter drainage bag was not documented prior to the change being made. These omissions resulted in inaccurate information in the resident's clinical record. The resident in question was admitted with diagnoses including a fusion of the spine, muscle weakness, and essential hypertension. The resident had an indwelling catheter and a surgical wound, as indicated in the Minimum Data Set. Despite these conditions, the facility staff performed surgical wound treatments and changed the urinary catheter drainage bag without documented physician orders. This lack of documentation was confirmed during interviews and record reviews with nursing staff, who were unable to provide the necessary physician orders for the treatments administered. The facility's policies required that verbal orders be recorded immediately in the resident's chart by the person receiving the order. However, there was a delay in entering the physician's orders into the resident's clinical records, with one order being entered more than seven hours after it was given. This delay in documentation had the potential to result in missed orders, as acknowledged by the Director of Nursing. The facility's failure to adhere to its own policies on documentation and order entry contributed to the deficiencies observed in the resident's care.
Incomplete Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, leading to deficiencies in their care. For Resident 1, who was admitted with diagnoses including Parkinson's disease, type 2 diabetes mellitus, and essential tremors, the care plan did not specify the frequency of neuro checks following an unwitnessed fall. This omission was identified during a review of the resident's care plan and confirmed by a Licensed Vocational Nurse, who acknowledged that the care plan was incomplete. Resident 2, admitted with conditions such as fusion of the spine, muscle weakness, and essential hypertension, also had an incomplete care plan. The care plan for Resident 2's indwelling urinary catheter did not specify critical details such as the date of the last catheter change, frequency, size, and type of catheter. Additionally, the care plan lacked information on the catheter drainage bag change and surgical wound treatment. This was confirmed during a review with an LVN, who noted the care plan was not specific or individualized. The facility's policy on comprehensive person-centered care plans, dated earlier in the year, mandates that care plans include measurable objectives and timetables to meet residents' needs. However, the care plans for both residents did not adhere to this policy, placing them at risk for not receiving necessary services and assistance, potentially leading to infection and injury.
Failure to Secure Urinary Catheter Leads to Deficiency
Penalty
Summary
The facility failed to provide proper care for a resident with an indwelling urinary catheter, specifically by not securing the catheter tubing to the resident's thigh. This deficiency was identified for one of five sampled residents, who was admitted with diagnoses including spine fusion, muscle weakness, and essential hypertension. The resident's care plan, initiated shortly after admission, indicated a high risk for complications such as urinary tract infections and included interventions to prevent tension on the urinary catheter by securing it with a leg strap. During an observation, the resident was found with the urinary catheter improperly secured, allowing movement through the statlock device on the resident's thigh. A registered nurse, responsible for changing the urinary catheter drainage bag, was unable to secure the catheter properly. The Director of Nursing confirmed that the catheter should have been secured to prevent dislodgement and potential trauma or infection. The facility's policy on urinary catheter care emphasized the importance of securing the catheter to reduce friction and movement at the insertion site.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to adhere to infection control procedures during the care of a resident, identified as Resident 2, who was on enhanced barrier precautions due to having an indwelling urinary catheter and a lower back surgical incision. The resident was admitted with diagnoses including fusion of the spine, muscle weakness, and essential hypertension. The care plan for the resident indicated a high risk for developing complications such as urinary tract infections, necessitating strict adherence to enhanced barrier precautions. During an observation, RN 1 was seen performing wound treatment and changing the urinary catheter drainage bag for Resident 2 without changing gloves after touching unclean surfaces. RN 1 did not change gloves after removing the resident's soiled wound dressing and continued to handle the urinary catheter and drainage bag with the same gloves. Additionally, RN 1 placed alcohol pad packets on the resident's bed, which was not a clean working area, and touched the basin under the bed with gloved hands before handling the new drainage bag. Interviews with RN 1 and the Director of Nursing (DON) confirmed that gloves should have been changed after each treatment and after touching soiled surfaces to prevent potential infections. The facility's policies on infection prevention and control, as well as the use of personal protective equipment, were not followed, as evidenced by RN 1's actions during the care of Resident 2.
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 their care. For one resident, there was no care plan for the use of buspirone, a psychotropic medication prescribed for anxiety. The absence of a care plan meant that the resident's behavior and medication effectiveness were not monitored, potentially leading to unnecessary medication administration and increased risk of altered cognition and falls. The Assistant Director of Nursing (ADON) and the Minimum Data Set Coordinator (MDSC) both acknowledged the lack of a care plan and its implications for the resident's health and safety. Another deficiency involved the failure to create care plans for residents using anticoagulant medications. One resident was prescribed apixaban, and another was on rivaroxaban, both without corresponding care plans to monitor for side effects such as bleeding and bruising. The MDSC and ADON highlighted the importance of these care plans in identifying risks and guiding staff in providing appropriate interventions. Without these plans, residents were at risk of health complications due to unmonitored medication side effects. Additionally, the facility did not develop care plans for the use of side rails and urinary catheters for certain residents. Two residents had side rails on their beds without care plans to prevent entrapment, and two others had indwelling urinary catheters without care plans to prevent urinary tract infections. The ADON confirmed the absence of these care plans and emphasized their necessity in ensuring resident safety and proper care. The facility's policies and procedures required comprehensive, person-centered care plans, but these were not followed, resulting in the identified deficiencies.
Failure to Rotate Injection Sites for Insulin Administration
Penalty
Summary
The facility failed to ensure that licensed nurses provided care in accordance with professional standards by not rotating subcutaneous insulin administration sites for three of the five sampled residents. This practice was observed during a review of insulin use, where it was found that repeated injections were administered in the same area, contrary to the guidelines provided by insulin manufacturers. The failure to rotate injection sites can lead to adverse effects such as lipodystrophy, bleeding, and bruising. Resident 34, who was admitted with type 2 diabetes mellitus, received insulin injections without proper site rotation. The resident's care plan indicated the need for insulin administration as ordered, yet the Location of Administration Report showed repeated use of the same injection sites over a period of time. The Assistant Director of Nursing (ADON) confirmed that the administration sites were not rotated, which could lead to poor absorption of insulin and insufficient blood sugar control. Similarly, Resident 11, who was receiving heparin for deep vein thrombosis prophylaxis, also experienced repeated injections at the same sites. The ADON acknowledged the lack of site rotation, which is necessary to prevent complications such as bleeding and irritation. Resident 5, with a history of type 2 diabetes and transient cerebral ischemic attack, also had insulin injections administered without proper site rotation. The ADON confirmed the repeated use of the same sites, which could potentially lead to adverse effects as outlined in the insulin manufacturer's guidelines.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to ensure proper documentation and reconciliation of controlled medications, as observed during a review of Medication Cart 2. The Controlled Substance / MAR Change of Shift Audit forms from 5/13/2024 to 6/2/2024 showed multiple missing entries, including signatures from oncoming and outgoing charge nurses and indications of whether the narcotic counts were correct. Licensed Vocational Nurse 2 (LVN 2) confirmed that the facility protocol required both nurses to count narcotics and sign the form at every shift change. The Director of Nursing (DON) stated that the facility policy was not followed, which could lead to medication going missing and delays in care. Additionally, the facility failed to administer medication to a resident, identified as Resident 249, who was admitted with a gastrostomy tube and required cholecalciferol oral liquid for nutritional support. On 6/5/2024, LVN 2 was unable to find the resident's medication in the cart, preventing administration. The Assistant Director of Nursing (ADON) acknowledged that residents would not receive the intended effects of their medications if not administered and emphasized the importance of timely reordering medications. The Operations Manager (OM) noted that the facility did not stock the liquid form of cholecalciferol, only tablets that could not be crushed. The facility's policy on Medication and Treatment Orders, last reviewed on 1/15/2024, required that medications be reordered from the pharmacy at least three days before the last dose to ensure availability. The failure to follow this policy resulted in the resident not receiving their prescribed medication, highlighting a lapse in the facility's medication management system.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that the drug regimen for two residents was free from unnecessary medications. For Resident 196, the facility did not provide an adequate indication for the use of apixaban, an anticoagulant medication. The resident was admitted with diagnoses including a fracture of the sacrum, hypertension, and atrial fibrillation. However, the physician's order for apixaban only stated it was for a blood thinner, without specifying the medical condition it was intended to treat, such as atrial fibrillation. This omission was identified during a review by the MDS Coordinator and the Assistant Director of Nursing, who acknowledged that the facility's policy requiring a specific clinical condition for medication orders was not followed. For Resident 11, the facility failed to monitor for adverse effects of heparin, another anticoagulant medication. The resident was admitted with conditions including atrial fibrillation, heart failure, and gastritis, and was receiving heparin for deep vein thrombosis prophylaxis. The order for heparin did not include instructions for monitoring adverse effects, such as bleeding and bruising, which are critical for patient safety. The Assistant Director of Nursing confirmed that the order lacked necessary monitoring instructions, which are essential to detect and report any adverse effects to the physician. The facility's failure to provide adequate indications for medication use and to monitor for adverse effects could lead to significant health risks for the residents. The facility's policy and procedures require that medication orders include the clinical condition being treated and that residents are monitored for potential adverse effects, but these protocols were not followed in the cases of Residents 196 and 11.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to manage and monitor the medication regimens of four residents, leading to deficiencies in promoting their highest practicable mental, physical, and psychosocial well-being. For one resident, the facility did not limit the PRN order for lorazepam to a 14-day duration, nor did it identify specific behaviors to monitor, as required by policy. This oversight was acknowledged by the Assistant Director of Nursing (ADON), who confirmed that the physician's order lacked necessary details to prevent unnecessary medication use. Another resident was prescribed buspirone for anxiety without documented monitoring of behavioral manifestations, such as restlessness leading to shortness of breath. The ADON and Director of Nursing (DON) both noted the absence of documentation for monitoring the resident's behavior, which is crucial for evaluating the medication's effectiveness and ensuring the resident's safety. The facility's policy mandates monitoring for efficacy and adverse consequences, which was not adhered to in this case. Additionally, the facility did not ensure appropriate physician's orders for monitoring target behaviors and adverse effects for residents receiving quetiapine and citalopram. One resident was given quetiapine without informed consent or proper documentation of the diagnosis and monitoring requirements. Similarly, another resident was prescribed citalopram without orders to monitor target behaviors and side effects. These lapses in medication management and monitoring placed residents at risk for adverse effects and unnecessary medication use.
Failure to Rotate Injection Sites for Medications
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of subcutaneous injections. For Resident 34, the facility did not rotate the injection sites for insulin administration, as evidenced by repeated injections in the same area of the abdomen over a period of time. This practice was confirmed by the Assistant Director of Nursing (ADON) during a review of the Medication Administration Record (MAR), who acknowledged that the sites should have been rotated to prevent adverse effects such as bruising and poor absorption of the medication. Similarly, Resident 5 experienced a lack of rotation in the administration of insulin injections. The MAR indicated that insulin was repeatedly administered in the same areas of the abdomen, which was again confirmed by the ADON. The failure to rotate injection sites was contrary to the manufacturer's guidelines and the facility's policy, which both emphasize the importance of site rotation to prevent complications like lipodystrophy. Resident 11 also suffered from improper medication administration practices, with repeated heparin injections in the same abdominal areas. The ADON confirmed that the sites were not rotated as required, which could lead to issues such as bleeding and irritation. The facility's policy and the manufacturer's guidelines for heparin administration both stress the necessity of rotating injection sites to avoid adverse reactions.
Deficiencies in Kitchen Hygiene and Food Safety Practices
Penalty
Summary
The facility failed to ensure that kitchen staff adhered to the dress code, which prohibits wearing excessive jewelry while handling food. During observations, a dietary aide and a dishwasher were seen wearing long, dangling necklaces and other jewelry that were not covered, contrary to the facility's policy and the Food Code 2017. The dietary manager confirmed that the policy was in place to prevent cross-contamination and infection control issues, as jewelry could potentially touch or fall into food. The facility also failed to properly label and store food items in the kitchen. Several opened food containers, including garlic spread, strawberry spread, and peeled garlic, were found unlabeled in the walk-in refrigerator. Additionally, mold was observed on blueberries, and produce was stacked unsafely to the ceiling, posing a risk of falling and contamination. Staff admitted that labeling and dating food items were necessary to prevent foodborne illnesses and that eating personal food in the kitchen could lead to cross-contamination. Furthermore, the kitchen equipment and utensils were not maintained in a clean condition. Observations revealed grease, dirt, and debris build-up on the oven, hood, stove, fryer, steam table, and floors. Cutting boards were stored while still wet, which could lead to bacteria and mold growth. The dietary manager acknowledged the unsanitary conditions and the potential for foodborne illnesses due to the lack of cleanliness in the kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. One significant issue involved a Licensed Vocational Nurse (LVN) who did not sanitize a reusable blood pressure cuff between uses on multiple residents. This oversight occurred with three residents, all of whom had various health conditions, including immunodeficiency and respiratory issues, which increased their vulnerability to infections. The LVN admitted to not cleaning the cuff due to being rushed, which was against the facility's policy requiring disinfection of such equipment between uses. Another deficiency was observed when the same LVN failed to don appropriate personal protective equipment (PPE) while providing care to a resident under enhanced barrier precautions. The resident had a urinary catheter and a gastrostomy tube, necessitating the use of gloves and a gown to prevent contamination. The LVN only wore gloves, neglecting to wear a gown, which could have exposed both the resident and the LVN to potential infections. This was contrary to the facility's policy on enhanced barrier precautions, which mandates the use of full PPE during high-contact care activities. Additional issues included the failure to change a resident's bilevel positive airway pressure (BIPAP) machine facemask weekly, as required by the facility's policy, and the improper handling of mechanical lift slings, which were used on multiple residents without being washed. Furthermore, nasal cannulas for two residents were not labeled with the date of the last change, making it difficult to ensure they were replaced weekly as per the facility's infection control policy. These practices increased the risk of cross-contamination and infection among residents.
Failure to Provide Privacy Cover for Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity and respect of Resident 249 by not providing a privacy cover for the resident's urinary catheter bag. This deficiency was identified during an observation and interview with Certified Nursing Assistant 3 (CNA 3) in the resident's room, where it was noted that the urinary catheter bag was uncovered. CNA 3 acknowledged that a privacy cover should have been provided to promote the resident's dignity. Resident 249 was admitted to the facility with diagnoses including Alzheimer's disease, acute kidney failure, and retention of urine, and had an order for an indwelling Foley catheter. The facility's policy on dignity, last reviewed in January 2024, mandates that residents be cared for in a manner that enhances their well-being and self-esteem, explicitly stating that urinary catheter bags should be covered. The Assistant Director of Nursing (ADON) confirmed that the urinary catheter bag should have had a privacy cover to ensure the resident's dignity and respect.
Failure to Assist Resident with Advance Directive Formulation
Penalty
Summary
The facility failed to offer assistance with formulating an Advance Directive (AD) to a resident or their representative upon admission. This deficiency was identified during a review of advance directive care for one of the two sampled residents. The resident, admitted with type 2 diabetes mellitus, was noted to have intact cognition and required varying levels of assistance with activities of daily living. Despite this, there was no documented evidence that the AD was discussed with the resident or their representative during the care conference meeting. Interviews with the Social Services Director (SSD) and the Assistant Director of Nursing (ADON) confirmed the absence of documentation regarding the discussion of ADs. The SSD acknowledged the importance of discussing ADs to ensure the healthcare team is aware of the resident's medical care preferences. The facility's policy, last reviewed in January 2024, mandates that the SSD or designee inquire about the existence of any written AD prior to or upon admission and provide written information about the right to refuse or accept medical treatment and to formulate an AD.
Improper LALM Setting for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for a resident by not setting the low air loss mattress (LALM) according to the manufacturer's guidelines. The resident, who was admitted with conditions including type two diabetes mellitus and a transient cerebral ischemic attack, was at risk for pressure ulcers and required a pressure-reducing device for the bed. Despite the resident's weight being documented as 195 pounds, the LALM was set to a weight range of 660 to 750 pounds, which was not in accordance with the resident's actual weight. Observations and interviews with facility staff, including a Certified Nursing Assistant, the Director of Staff Development, a Treatment Nurse, and the Assistant Director of Nursing, confirmed that the LALM should be set to the resident's weight to prevent skin breakdown and discomfort. The incorrect setting of the LALM had the potential to increase pressure on the resident's skin, potentially leading to the reopening of existing pressure ulcers. The manufacturer's guidelines also indicated that the mattress should be adjusted according to the resident's weight and comfort.
Failure to Prevent Unattended Medications
Penalty
Summary
The facility failed to ensure that medications were not left unattended and readily available to residents, specifically for one resident who was not authorized to self-administer medications. This deficiency was identified during observations and interviews with staff and the resident. The resident, who was admitted with multiple diagnoses including a fracture, hypertension, and immunodeficiency, did not have an assessment or physician's order for self-administration of medications. Despite this, medications were found on the resident's nightstand and bedside table. During observations, a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) were present in the resident's room but did not remove the medications. The LVN initially mistook the medication bottles for shampoo and did not investigate further, while the CNA was unsure of the purpose of the medications and did not remove them. The resident stated that the medications belonged to her and that sometimes the nurses helped her take them, indicating a lack of consistent supervision and adherence to the facility's medication policies. The facility's policies require that medications should not be left at the bedside unless the resident is assessed and authorized to self-administer them. The Assistant Director of Nursing (ADON) and a Treatment Nurse confirmed that the resident did not have the necessary assessment or physician's order for self-administration. The presence of medications at the bedside posed a risk of accidental ingestion or overuse, as the resident had an order for a similar topical medication that could lead to overuse if both were applied.
Inadequate Catheter Care Leading to Potential Infection Risks
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary catheters, leading to potential risks of catheter-associated urinary tract infections (CAUTI). For Resident 249, the urinary catheter tubing was observed to be kinked, and the catheter bag was touching the floor. This was noted during an observation with a Certified Nursing Assistant (CNA), who acknowledged that the catheter bag should be kept off the floor for infection control and that the tubing should be free of kinks to allow urine to flow freely. The Assistant Director of Nursing (ADON) confirmed that the catheter should be kept off the floor to prevent ascending infections and that the tubing should be inspected frequently to prevent backflow of urine, which could result in infection. Similarly, Resident 40's indwelling catheter bag was placed on the floor by a Physical Therapist (PT) during a transfer from a wheelchair to a bed. The PT admitted to placing the bag on the floor to expedite the transfer, acknowledging the increased risk of infection. The ADON reiterated that staff must adhere to standards of practice by keeping the catheter bag off the floor to prevent UTIs, which could lead to confusion, falls, and rehospitalization. The facility's policy on catheter care, last reviewed in January 2024, emphasizes the importance of keeping catheter tubing and drainage bags off the floor to prevent infections.
Failure to Label IV Medication Bag and Tubing
Penalty
Summary
The facility failed to properly label the intravenous (IV) medication bag and tubing for a resident, which could lead to complications in medication administration. The resident, who was admitted with conditions including malignant neoplasm of the breast, secondary malignant neoplasm of bone, chronic kidney failure, and hypercalcemia, was receiving Sodium Chloride 0.9% intravenously as per the physician's order. However, during an observation, it was noted that the IV medication bag and tubing were not labeled with essential information such as the resident's name, medication details, start time, and the person who administered it. The lack of labeling was confirmed during an interview with a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON), who acknowledged the potential dangers of administering unlabeled medication. The facility's policy requires that medication containers be changed every 24 hours and administration sets for continuous infusion every 72 hours, but without proper labeling, adherence to these protocols could not be ensured. This oversight had the potential to increase the resident's risk for complications such as bacterial growth in the tubing and incorrect medication administration.
Failure to Assess Entrapment Risk and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to properly assess the risk of entrapment and obtain informed consent before installing bed rails for two residents. Resident 11 was admitted with diagnoses including age-related osteoporosis, dementia, and abnormal posture. Despite the resident's inability to make medical decisions, the facility did not conduct an assessment for entrapment risk or obtain informed consent before installing a half side rail on the resident's bed. Observations confirmed the presence of the side rail, and the Assistant Director of Nursing acknowledged the absence of necessary assessments and consents. Similarly, Resident 20, admitted with conditions such as lack of coordination and syncope, also had a half side rail installed without prior assessment or informed consent. The resident's medical records did not indicate any order for side rail placement, and the Assistant Director of Nursing confirmed the lack of required documentation and assessments. Observations of the resident's room confirmed the presence of the side rail. The facility's policy on bed safety and bed rails, last reviewed in January 2024, prohibits the use of bed rails unless specific criteria are met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The policy outlines a comprehensive assessment process to determine the risk of entrapment, which was not followed in these cases. The facility's failure to adhere to its own policies and procedures resulted in the installation of bed rails without proper assessment and consent, posing potential risks to the residents.
Deficiency in GT Medication Administration Competency
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) had the necessary competencies and skills to care for residents' needs, specifically in administering medications via a gastrostomy tube (GT). During an observation, LVN 2 was seen administering water through a resident's GT using a syringe and a slow push method, contrary to the facility's policy which requires medications to be administered via gravity. This method of administration was not in line with the resident's care plan and had the potential to cause discomfort or dislodge the GT. The Director of Staff Development confirmed that LVN 2 did not have a skills checklist for GT medication administration and had not attended the last in-service training on this topic. The facility's policy requires medications to be administered via gravity, and the Assistant Director of Nursing emphasized the importance of staff being competent in this procedure to prevent potential harm to residents. The deficiency was identified through observation, interviews, and record reviews, highlighting a gap in staff training and competency assessment related to GT medication administration.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of eight percent. This was observed during a survey where two medication errors occurred out of 25 opportunities. The errors affected one resident, who did not receive their prescribed medications, cholecalciferol and fluticasone, as ordered by their physician. The resident, who was admitted with conditions including gastrostomy status and retention of urine, was supposed to receive these medications for nutritional support and to relieve nasal symptoms due to oxygen use. During the observation, an LVN was unable to administer the medications because they were not available in the medication cart. This omission was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that not administering the medication as ordered constitutes an error. The facility's policy defines medication errors as any preparation or administration of drugs not in accordance with physician's orders, including omissions and wrong timing.
Unlabeled Albuterol Nebules Found in Medication Cart
Penalty
Summary
The facility failed to ensure the safe provision of pharmaceutical services during an inspection of a medication cart. Specifically, five unpackaged and unlabeled albuterol nebules were found in the bottom right drawer of Medication Cart 2. The Licensed Vocational Nurse (LVN) present during the observation acknowledged that the nebules were not in a labeled box, were not labeled to identify the resident to whom they belonged, and were not labeled with an opened date. The LVN admitted to not knowing the owner of the unlabeled nebules and stated that they should have been discarded instead of stored in the cart. This oversight had the potential to result in medication being administered to the wrong resident or the use of expired medication. The Director of Nursing (DON) reviewed the facility's policy and procedure regarding medication storage and confirmed that the proper process was not followed. According to the policy, nebules should be kept enclosed in a foil packet and labeled when opened. The DON emphasized the importance of removing and disposing of unlabeled medications to prevent medication errors. The facility's policy mandates that all drugs and biologicals be stored in the packaging, containers, or other dispensing systems in which they are received, and only the issuing pharmacy is authorized to transfer medication between containers. The failure to adhere to these procedures resulted in the deficient practice observed during the survey.
Inaccurate Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident during medication administration. Specifically, a Licensed Vocational Nurse (LVN) documented the administration of cholecalciferol, a Vitamin D supplement, to a resident when it was not actually administered. This error was identified during a review of the Medication Administration Record (MAR) for the resident, who had been admitted with diagnoses including gastrostomy status and retention of urine. The physician's order required the administration of cholecalciferol via gastrostomy tube once daily for nutritional support. During an interview, the LVN admitted to mistakenly marking the medication as administered, despite not having the medication available on that day. The Assistant Director of Nursing (ADON) confirmed that documenting medications as administered when they were not is inappropriate, as it can lead to potential problems for the resident. The facility's policy on administering medications requires that medications be administered safely, timely, and as prescribed, with the individual administering the medication initialing the MAR after each administration.
Failure to Properly Explain Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the arbitration agreement was explained to residents in a manner they could understand, leading to confusion and lack of awareness about their rights. Specifically, Resident 246's representative, Family Member 1, signed the arbitration agreement without knowing it could be rescinded within 30 days. The representative was not fully informed about the agreement's implications and was unaware that signing it was not a condition for admission. Similarly, Residents 4 and 40 signed the arbitration agreement without understanding its content or the option to rescind it within 30 days. Both residents had moderately impaired cognition and required varying levels of assistance with activities of daily living. Despite this, they were not adequately informed about the arbitration process or their rights to withdraw from the agreement. Interviews with the Admissions Director and Assistant Director of Nursing revealed that the arbitration agreement was part of the admission packet and signed electronically. However, the Admissions Director admitted to not explaining the rescission option to residents or their representatives. The facility's policy required clear communication about the right to withdraw from the agreement, which was not adhered to, resulting in the deficiency.
Failure to Screen Visitors and Staff for COVID-19 During Outbreak
Penalty
Summary
The facility failed to screen eight of ten sampled visitors and three of ten sampled staff for COVID-19 during a period from 4/23/2024 to 4/26/2024 while the facility was experiencing a COVID-19 outbreak. Observations on 4/29/2024 revealed that the front desk was unattended, and the Visitor and Employee Daily Monitoring Log had missing temperature entries and unanswered COVID-19 screening questions. Interviews with staff confirmed that the required screening procedures were not consistently followed, despite the facility's policy and the outbreak notification from the Los Angeles County Department of Public Health mandating such measures. The Infection Preventionist and the Director of Nursing acknowledged the lapses in screening, with the DON stating that they could not enforce compliance among visitors. The facility's policy required all employees and visitors to check their temperature and answer screening questions to prevent the spread of COVID-19. However, the logs reviewed indicated that these procedures were not adhered to, potentially compromising the health and safety of residents and staff during the outbreak.
Failure to Accommodate Room Change Request
Penalty
Summary
The facility failed to provide reasonable accommodations for Resident 4's needs and preferences when Family Member 1 (FM 1) requested a room change. Resident 4, who was admitted with diagnoses including cerebrovascular disease, pneumonitis, and Alzheimer's disease, did not have the capacity to make decisions. FM 1, the responsible party, requested a private room three weeks prior due to complaints from other residents about FM 1 staying in the room. Despite the request being communicated to the Admission Coordinator (AC) and mentioned in a standup meeting, no action was taken to move Resident 4, even though there were vacant rooms available during the requested period. The Assistant Director of Nursing (ADON) and the Administrator (ADM) were not aware of FM 1's request, and the facility's policy indicated that room changes should consider resident preferences, which was not adhered to in this case. Interviews with staff revealed that Resident 8, who was Resident 4's roommate, also requested a room change due to discomfort with FM 1 sleeping in the room. The AC acknowledged the request but cited a lack of vacant rooms at the time, although records showed that rooms were available. The ADON admitted that the room change should have been made when rooms were vacant, and the ADM stated that room changes are based on clinical needs rather than resident or family requests. This lack of communication and failure to act on the room change request potentially impacted the psychosocial well-being of Resident 4 and other residents involved.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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