Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Rowland during CMS and state inspections, most recent first.
Inaccurate MDS documentation affected two residents. One resident with dementia and a history of falls had an AIR and transfer summary showing a fall and hospital transfer, but the MDS did not reflect the fall. Another resident with ESRD and palliative care had a DSROS showing discharge home with hospice, but the MDS did not include the discharge destination. The DON and MDSC confirmed the MDS entries were incomplete or incorrect.
The facility failed to develop individualized care plans for two residents with significant cognitive and functional needs. One resident had dementia, Alzheimer’s disease, and psychosis, but staff confirmed no care plan was in place to address the dementia diagnosis. Another resident with dementia, heart failure, and COPD had a fall with a skin tear, but staff stated there was no care plan specific to the fall event. The DON stated care plans should include resident-specific problems, goals, and nursing interventions, and the facility policy called for measurable objectives and timetables.
Failure to Follow MD Orders and Document COC Two residents had deficient care related to notification and documentation. One resident with HF, acute respiratory failure, and oxygen therapy had an SpO2 of 88% despite an order to notify the MD if saturation fell below 91%, but the record showed no MD notification or documented interventions when the resident was difficult to arouse and breathing slow and shallow. Another resident with dementia, HF, and COPD was found on the floor with a skin tear, but the record did not show COC documentation or evidence that the MD and family were notified after the fall/incident.
Unsafe food storage practices were observed in Kitchen 1 when a bag of bagels in the freezer was not labeled and trays in the refrigerator and walk-in freezer contained ham, strawberries, and ice cream cups with dates that the DS stated had no clear use-by or expiration date. The DS said these items should have been removed and discarded, and the DON stated expired food should not be present in the kitchen refrigerator. Facility policy required refrigerated and frozen foods to be covered, labeled, and dated with a use-by date.
Unsafe Storage of Resident Food Items: Two residents' refrigerators contained a container of ultra pasteurized milk past its use-by date and a gallon of whole milk with no open date. The DS stated expired or unlabeled foods should be discarded, nursing staff were responsible for checking and cleaning the refrigerators, and the facility policy required resident foods to be labeled with the resident's name, item, and use-by date.
Improperly Covered Trash Bins and Trash Accumulation: Two large trash bins were observed overfilled with trash, left open, and surrounded by trash on the floor. An outside trash can near the entrance was also observed without a lid and containing food waste and wrappers that had attracted flies, while additional trash, gloves, and cigarette butts were scattered throughout the parking lot. The DS and DON stated the bins should be kept closed for infection control and to prevent contamination and rodent infestation.
Incomplete and inaccurate resident medical record documentation: The facility failed to document wound treatments for one resident with a stage 4 sacral PU, failed to record a physician transfer order for another resident after a fall and hospital transfer, and entered an inaccurate oxygen saturation reading for a resident who had already expired. The DON and nursing staff acknowledged the missing and incorrect charting in the TAR, physician order record, and vitals summary.
An LVN administered medications to two residents using a medication tray that was visibly soiled and not sanitized between uses, despite the facility policy requiring contaminated trays to be cleaned and disinfected before reuse. Staff also left a resident’s disposable razors and another resident’s toothbrush unlabeled and stored on a sink in a shared bathroom instead of in labeled containers, and the DON stated these items should be stored in wash basins in the residents’ dressers to avoid the spread of infection.
Resident Not Addressed by Proper Name: A resident with dementia, dysphagia, and a history of falls was documented as dependent on staff for eating and described by staff as a "feeder." RN and the DON acknowledged that this label was used for residents needing feeding assistance, and the DON stated it was inappropriate because it was a dignity issue and could cause embarrassment. The facility policy required staff to address residents by their name of choice and not by diagnosis or care needs.
A resident with impaired decision-making capacity and diagnoses including OA, anxiety disorder, and schizophrenia had an AD that was not kept in the medical chart. The SSD reviewed the AD and stated it should be in the chart for staff access, while MR staff said it was stored in the MR office and was not easily accessible, which was inconsistent with facility policy requiring ADs to be readily retrievable in the resident record.
A resident with psychosis, dementia, Alzheimer's disease, and depression had an order for sertraline for depression m/b, but the order did not document the specific behaviors or symptoms supporting use of the antidepressant. The DON stated the m/b was missing, staff should have clarified the order with the MD, and there was no documentation that nursing staff contacted the MD or recorded progress notes about the issue.
A resident with schizophrenia, anxiety disorder, and significant cognitive impairment had a PASRR I that incorrectly indicated no SMI, ID/DD, or RC. The PASRR I stated the resident did not have a diagnosed SMI such as schizophrenia, even though the diagnosis was documented in the record. During review, the AADM acknowledged schizophrenia is a SMI and that identifying it on the PASRR I was important so the resident would be assessed for a PASRR II.
Failure to Revise Care Plan After a Fall: A resident with a history of falls, CVA, dysphagia, and dementia had an unwitnessed fall and was later transferred to an acute care hospital, but the care plan was not updated after the change in condition. RN and DON both stated the care plan should have been revised after the fall, and the facility policy called for interdisciplinary review and revision after falls and other clinically significant events.
A resident with pneumonitis, cardiomyopathy, anemia, and severe cognitive impairment had nasal cannula oxygen tubing that was not labeled with the date and time it was last changed. An IPN and the DON confirmed the tubing should be labeled per facility policy, which required oxygen supplies to be changed on the 15th and end of each month with the date and time documented.
A resident with ESRD and HF had an order for dialysis three times weekly, and staff documented pre-dialysis vitals and vitals at the dialysis center. However, when the resident returned to the facility after dialysis, the chart did not show that post-dialysis vital signs were checked and documented, despite RN and DON statements that this was standard practice and required by the facility's dialysis policy.
Surveyors found that the facility did not follow physician orders and internal policies for fall prevention for multiple residents. Two residents with intact cognition and significant medical conditions had active orders for bilateral floor mats, but observations showed no mats at their bedsides. Several residents who required assistance with ADLs experienced falls, including one with a documented forehead laceration, yet post-fall risk assessments were not completed as required. The DON reported that fall risk assessments are to be done on admission, periodically, and after a fall, and that residents with orders for floor mats must have them in place, but the records and observations did not reflect this practice.
Surveyors found that three residents receiving oxygen therapy did not receive safe and appropriate respiratory care. One resident with respiratory and heart failure had a nasal cannula that was not dated and was found touching the floor. Another resident with end-stage renal disease and peripheral vascular disease had an order for oxygen and MAR instructions to change and label oxygen tubing and the storage bag, but documentation showed the tubing was not changed, there was no oxygen care plan, and the nasal cannula was touching the floor without a storage bag at the bedside. A third resident with respiratory failure and dependence on supplemental O2 had an order interpreted by the IPN as requiring continuous oxygen, yet was repeatedly observed in a motorized wheelchair without oxygen, and the nasal cannula was later found hanging from a restroom doorknob and touching the floor. Facility policy and staff interviews confirmed that oxygen supplies were required to be dated, changed biweekly, stored in bags when not in use, and monitored by nursing staff, but these practices were not followed for these residents.
Surveyors found that meals were not prepared or served according to the approved menus on two consecutive lunch services. Residents received alternate items, such as pizza and other substituted foods, instead of the planned, dietitian-reviewed menu selections, and no advance notice of these changes was given to residents. The DSS was present in the kitchen but did not verify that the correct menu items were prepared or that meals matched physician orders, and residents were not informed of menu changes as required. The cook reported substituting available foods when ordered chicken did not arrive, did not notify the DSS, and admitted not reviewing or following the new menus, despite job descriptions and facility policy requiring adherence to established menus and limiting menu changes to the DSS and RD.
Surveyors found that two residents with ordered mechanically altered diets did not consistently receive food in the prescribed texture, and that staff did not reliably verify food consistency before trays left the kitchen. One resident on a mechanical soft/easy‑to‑chew diet was observed receiving hard broccoli, intact meat later cut by staff, and large pieces of fruit, which the resident reported were difficult to chew and swallow. Another resident with dysphagia on a minced and moist diet was served a whole cheese sandwich with bread edges, apple pie with crust, and soup containing bacon and vegetables, and reported that the food pieces were too large and not easy to swallow. CNAs stated that sandwiches arrived whole and were cut by nursing staff without clear guidance on size, while the Dietary Supervisor and DON confirmed that dietary staff were responsible for preparing correct textures and that both dietary and nursing staff were expected to check food consistency against facility policies for mechanical soft and minced and moist diets.
A resident with cerebrovascular disease, dysphagia, and vascular dementia, who required significant assistance with ADLs and was dependent for toileting, did not have a functioning call light in their room on multiple occasions. When the resident pressed the call light, it did not activate inside or outside the room, and the resident reported that staff did not respond when assistance was needed. An LVN and CNA stated that all staff were responsible for checking and answering call lights and that the system was essential for residents to request help, yet the CNA, who believed the call light had been checked and was working, confirmed during observation that it did not function. The DON stated that maintenance and nursing staff were responsible for ensuring call lights worked each shift, and facility policy required prompt response to call lights within 5–6 minutes.
Two residents did not have their IV site or TPN tubing properly labeled with the date, time, and initials as required by facility policy. One resident's peripheral IV site lacked labeling upon dressing change, and another resident's TPN tubing was not labeled when hung. Nursing staff and the DON confirmed these omissions during interviews and observations.
Multiple residents receiving oxygen therapy and respiratory treatments were found with equipment such as oxygen tubing, nebulizer tubing, and nasal cannulas in unsanitary conditions, including being placed on the floor or not stored in clean bags. In addition, required safety signage for oxygen use was not posted outside a resident's room. Staff interviews confirmed these practices were inconsistent with facility policy and infection control standards.
Two residents were placed on bedrails without documented safety assessments, physician orders, or informed consent, contrary to facility policy. One resident with cognitive impairment and another with intact cognition both had bedrails installed without attempts at alternatives or proper documentation, as confirmed by staff interviews and record reviews.
A nurse administered five scheduled medications to a resident with severe cognitive impairment and a feeding tube earlier than the prescribed time, outside the facility's allowed one-hour window. The DON confirmed that this practice was not in accordance with facility policy, which requires medications to be given within one hour before or after the scheduled time to ensure effectiveness.
A nurse administered five medications via gastrostomy tube to a resident with severe cognitive impairment and multiple diagnoses earlier than the scheduled time, resulting in a medication error rate of 17.86%, which exceeded the acceptable threshold. The facility's policy and the DON confirmed that medications should be given within a specific time window to prevent errors.
Surveyors found that a medication cart was left unlocked and unattended by an LVN, and a resident with COPD and other conditions was keeping prescribed inhalation medication in their bedside drawer without proper assessment or authorization. The DON and facility policies confirmed that medications must be secured and not kept at the bedside unless specific procedures are followed.
Surveyors identified that two of four kitchen sanitization buckets were not maintained at the correct chemical concentration, and required checks were not documented. Additionally, expired salsa containers were found in the refrigerator, and opened pasta noodles in dry storage were not labeled with open or use-by dates, contrary to facility policy. The Dietary Supervisor confirmed the importance of proper labeling and sanitization to ensure food safety.
Multiple residents requiring isolation or enhanced barrier precautions did not have proper signage or PPE carts outside their rooms, and staff failed to consistently use required PPE during care activities. A disposable gown was left hanging inside a room instead of being discarded, and the facility lacked a water management diagram to assess Legionella risk, all contrary to facility policy and orders.
A resident with severe cognitive impairment and total dependence for eating was assisted with meals by a CNA who stood over the resident rather than feeding at eye level, contrary to facility policy and staff expectations. Both the CNA and DON confirmed that feeding should occur at eye level to maintain dignity and proper monitoring.
A resident with hemiplegia and muscle weakness was found with their call light on the floor and out of reach, despite care plan and facility policy requiring it to be accessible on the resident's strong side. Staff confirmed the resident could not access the call light, resulting in a failure to accommodate the resident's needs.
A resident with significant medical conditions and moderately impaired cognition did not have an Advance Directive or AD Acknowledgement Form in their medical record. Staff interviews and policy review confirmed these documents should be present and updated with each admission or readmission, but they were missing from both the paper and electronic records.
A CNA was hired without a documented background check through the OIG database, contrary to facility policy requiring such checks to prevent employment of individuals with a history of abuse, neglect, or exploitation. Interviews with the DSD and DON confirmed the omission and the importance of pre-employment screening for staff and resident safety.
A resident with multiple chronic conditions and an indwelling Foley catheter was found with the catheter tubing not secured to the thigh, as required by facility policy and care plan. Both nursing staff and the DON confirmed the tubing was not properly attached, and the securement device was not taped, contrary to established procedures intended to prevent pulling and injury.
A resident with a biliary drain was found to have yellow biliary fluid leaking onto the floor beneath the drainage bag. Nursing staff acknowledged that the drainage bag should not be leaking, and the DON confirmed this posed an infection control concern. Facility policy required proper management of biliary drains to prevent such incidents.
A resident with multiple chronic conditions was receiving Lovenox for DVT prophylaxis when a consultant pharmacist recommended specifying a duration of therapy. The facility did not document that the attending physician was notified of this recommendation, contrary to policy, resulting in the recommendation not being addressed.
A resident with cognitive impairment and multiple diagnoses received antibiotics for a UTI without documented symptoms or meeting facility criteria, as required by the Antibiotic Stewardship Program. Staff interviews and record reviews confirmed the absence of necessary documentation and failure to follow established protocols for monitoring and documenting changes in condition.
A facility failed to follow its hand hygiene protocols when a CNA did not wash their hands after interacting with a resident diagnosed with C. diff. The resident was on contact isolation, requiring strict adherence to handwashing procedures. Despite removing protective gear, the CNA exited the room without washing hands, contrary to the facility's policy, which mandates handwashing with soap and water after contact with residents with infectious diarrhea.
Two residents in a LTC facility were found to have cigarettes and lighters in their possession, smoking unsupervised despite requiring supervision due to mental health and vision impairments. The facility failed to implement its smoking policy, creating potential fire hazards, especially with an oxygen machine present in one resident's room.
The facility failed to maintain safe food handling practices, with an ice scoop stored in a container with a brown liquid, leading to the distribution of contaminated ice to residents. Additionally, food storage practices were inadequate, with items not dated or labeled, increasing the risk of food-borne illnesses.
The facility failed to transmit MDS assessments within 14 days for 23 residents, as required. The Assistant Administrator, responsible for the task, did not realize the due dates, leading to the delay. Additionally, the facility had not trained other MDS staff on the transmission process, as per their policy.
The facility failed to provide proper care for GT management for two residents, leading to potential infection risks. One resident's GT tubing was left open, and another's GT site lacked a required dressing, contrary to care plans and facility policy.
The facility failed to manage oxygen therapy properly for several residents, as observed in unlabeled oxygen tubing and improper nasal cannula placement. This deficiency involved residents with conditions like COPD and respiratory failure, where oxygen tubing lacked date labels, risking infection, and nasal prongs were not correctly positioned, affecting oxygen delivery.
The facility failed to provide dialysis emergency kits for two residents requiring dialysis services, placing them at risk for excessive bleeding. Observations revealed the absence of these kits at the residents' bedsides, confirmed by nursing staff. The DON admitted the lack of policies to ensure kit availability.
The facility did not post accurate nurse staffing information in a prominent location, as required. Staffing details were found inside the North Nurses' Station, inaccessible to residents, family, and visitors. The Director of Staff Development was unaware of the requirement for accessible posting, leading to potential misinformation about staffing levels.
The facility failed to implement Gradual Dose Reductions (GDR) for two residents and did not limit PRN orders for psychotropic medications to 14 days for three residents. This oversight led to the potential inappropriate use of psychotropic drugs, affecting the residents' well-being. The facility did not adhere to its policy requiring PRN orders for antipsychotic medications to be reassessed every 14 days.
The facility failed to implement a comprehensive infection prevention and control program, lacking measures to monitor Legionella and other pathogens in water systems. Additionally, a resident with a Foley catheter was not provided with necessary Enhanced Barrier Precautions, such as signage and PPE, increasing the risk of infection.
A facility failed to include a resident's Advance Directive (AD) in their medical chart, despite the resident having both an AD and a POLST. The resident was alert and oriented, with intact cognitive abilities. Interviews with the Social Services Director and Director of Nursing revealed that the facility's policy required the AD to be prominently displayed in the medical record, which was not done, posing a risk of not honoring the resident's wishes.
A resident with dementia and epilepsy was left exposed during a bed bath by a CNA, who failed to follow the facility's policy of covering the resident and changing bath water as needed. The privacy curtain was open, and another CNA entered the room, further compromising the resident's privacy.
A facility failed to implement its policy on Translation and Interpretation services for a resident with limited English proficiency (LEP). The resident, who preferred Chinese, was communicated with by an LVN using body language, without a communication board at the bedside. The Activities Director confirmed the absence of necessary communication tools, which could lead to unmet needs.
A resident with a history of falls and requiring assistance with daily activities waited 31 minutes for help after activating the call light. Despite the facility's policy to respond within five to six minutes, staff interviews confirmed the delay, posing a risk of the resident attempting to move unassisted, potentially leading to a fall or injury.
Inaccurate MDS Documentation for Fall and Discharge Destination
Penalty
Summary
The facility failed to ensure accurate MDS documentation for two sampled residents. Resident 12 was admitted with diagnoses including history of falling, dysphagia, and dementia, and the MDS dated [DATE] indicated severely impaired cognition and no fall in the month prior to admission or reentry. However, an AIR dated 3/11/2026 at 12:13 am documented that Resident 12 was found on the floor beside the bed, assessed, and placed on fall precautions, and a transfer summary dated 3/11/2026 at 2:17 am documented transfer to an acute care hospital after a fall. During interview and record review, the MDSC stated Resident 12 had a fall on 3/11/2026 and the MDS documentation was incorrect. Resident 116 was admitted with diagnoses including end stage renal disease, anemia, and encounter for palliative care. A DSROS dated 3/3/26 at 10:12 am documented discharge home with hospice care, but the MDS dated [DATE] did not include the discharge location/destination. The MDS showed severely impaired cognition and dependence on staff for oral, personal, toileting hygiene, showers, footwear, and lower body dressing. The DON and MDSC both stated the discharge location was not completed in the MDS, and the MDSC stated Resident 116 was discharged home on 3/3/26 but the discharge destination section was left blank.
Failure to Develop Individualized Care Plans for Dementia and a Fall
Penalty
Summary
The facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans for two residents. One resident was admitted with diagnoses including unspecified psychosis, dementia, and Alzheimer’s disease, and the MDS showed moderately impaired cognition with varying levels of assistance needed for eating, dressing, hygiene, and toileting. During record review and interview, RN 1 stated there was no care plan developed and implemented for the resident’s dementia since admission, and the DON confirmed that no care plan had been initiated to address the dementia diagnosis. A second resident was admitted with diagnoses including dementia, heart failure, and COPD, and the H&P stated the resident did not have the capacity to understand and make decisions. The MDS showed moderately impaired cognition and dependence or maximal assistance for toileting hygiene, eating, personal hygiene, and showering. RN 1 reviewed the record and stated the resident had a fall event when the resident was found on a floor mat crawling with a skin tear to the right forearm, and stated there was no care plan that specifically addressed the fall incident. The DON stated care plans should include resident-specific problems, goals, and nursing interventions, and that a care plan should be created whenever there was an incident such as a fall. The facility’s care plan policy stated that an individualized comprehensive care plan includes measurable objectives and timetables to meet the resident’s medical, nursing, mental, and psychological needs, and that care plans reflect treatment goals, timetables, and measurable outcomes.
Failure to Follow Physician Orders and Document Change in Condition
Penalty
Summary
The facility failed to follow a physician order for Resident 123 when the resident’s oxygen saturation dropped below the ordered threshold. Resident 123 was admitted with diagnoses including heart failure, acute respiratory failure, and palliative care, and the record showed the resident was on oxygen therapy and required assistance with multiple activities of daily living. The physician order in the order summary required staff to notify the MD if oxygen saturation was below 91%, and the care plan directed staff to monitor vital signs and notify the MD of significant abnormalities. At 2:00 AM, Resident 123 was documented as sleeping, difficult to arouse, breathing slow and shallow, with an oxygen saturation of 88%. RN1 stated the MD should have been notified per the order and that there was no documentation showing the MD was notified or that interventions were provided. The DON also stated there was no documentation that the MD was notified when the resident’s oxygen saturation was 88%, and that the licensed nurse did not follow the MD order or document any interventions when the resident was difficult to arouse and breathing slow and shallow. Resident 123 was DNR and expired later that morning. The facility also failed to complete change of condition documentation and notify the physician and family after Resident 76 was found on the floor with a skin tear to the right forearm. Resident 76 had diagnoses including dementia, heart failure, and COPD, and the H&P stated the resident did not have the capacity to understand and make decisions. The record showed Resident 76 was found on a floor mat crawling with a skin tear, but RN1 and the DON both stated the behavior note did not show that the physician and family were notified and was not equivalent to a COC documentation. Both stated that a fall/accident was a change in condition requiring assessment, physician notification, family notification, and documentation in the COC note.
Unsafe Food Storage Practices in Kitchen 1
Penalty
Summary
Safe food storage practices were not followed in Kitchen 1 when surveyors observed multiple food items that were not properly labeled or were past their dated storage time. During a concurrent observation and interview with the Dietary Supervisor inside the kitchen on 6/30/26 at 8:43 AM, a bag of bagels in the freezer was found without a label, a tray in the refrigerator contained 3 bags of ham dated 6/26/26, and a tray in the walk-in freezer contained 5 strawberries and 2 orange ice cream cups dated 6/27/26. The Dietary Supervisor stated there was no use-by or expiration date on these items and that, without a clear date, they should have been removed and discarded. During an interview with the Director of Nursing on 7/1/26 at 3:45 PM, the DON stated there should not be any expired food in the kitchen refrigerator and that the Dietary Supervisor was responsible for ensuring expired food was not present. The DON stated that when expired food was found, it should be thrown out in the trash. Facility policy titled Food Receiving and Storage required foods stored in the refrigerator or freezer to be covered, labeled, and dated with a use-by date, and the infection control policy stated the facility's practices were intended to maintain a safe, sanitary, and comfortable environment and help prevent transmission of diseases and infections.
Unsafe Storage of Resident Food Items
Penalty
Summary
The facility failed to ensure safe food storage practices for two residents' refrigerators by leaving a container of ultra pasteurized milk with a use-by date of 6/29/26 and a gallon of whole milk with no open date inside the refrigerators. During a concurrent observation and interview with the Dietary Supervisor, both items were found in the residents' refrigerators at the nurse stations, and the Dietary Supervisor stated that expired or non-labeled foods should be discarded. The Dietary Supervisor also stated nursing staff were responsible for checking and cleaning the residents' refrigerators and that items inside should have a use-by date or expiration date. During interviews, the DON stated expired food should not be placed inside residents' refrigerators because residents could get sick if they ate expired food. An LVN stated that when family members brought food for residents, nursing staff would place the items in the residents' refrigerators and label them with the resident's name, room number, and expiration day, and that food was only kept for one day. The facility's policy titled Food Receiving and Storage stated foods should be received and stored in a manner that complies with safe food handling practices and that all foods belonging to residents are labeled with the resident's name, the item, and the use by date.
Improperly Covered Trash Bins and Trash Accumulation
Penalty
Summary
The facility failed to properly cover two of three large trash bins as required by its Policy and Procedure on garbage disposal. During a facility tour on 6/30/26 at 8:00 AM, two large trash bins were observed overfilled with trash, with open lids and trash on the floor around the bin area. During an observation and interview outside in the parking lot at 9:18 AM, the Dietary Supervisor stated the two outside trash bins should be closed and that trash should not be discarded on the floor. The Dietary Supervisor also stated that open bins and trash on the floor could attract rodents and critters and that this was an infection control issue and not sanitary. On 7/1/26 at 3:15 PM, an outside trash can near the facility entrance was observed without a lid and containing leftover food containers, food wrappers, and soda cups that had attracted flies. Multiple pieces of trash were also observed throughout the parking lot, including discarded blue gloves, food wrappers, and cigarette butts. During an interview at 3:41 PM, the DON stated trash bins should always be covered with lids for infection control and that lids should be kept closed at all times to prevent cross contamination and rodent infestation. The facility's Sanitation policy stated garbage and refuse containers should be in good condition, waste properly contained in dumpsters/compactors with lids or otherwise covered, and garbage disposal areas maintained to prevent pests. The Infection Control policy stated the facility's infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and help prevent and manage transmission of diseases and infections.
Incomplete and inaccurate resident medical record documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three sampled residents by not documenting wound treatments, a physician transfer order, and an oxygen saturation reading. The report states these omissions involved Resident 9, Resident 12, and Resident 123, and that the missing or inaccurate documentation affected the medical record for each resident. Resident 9 was admitted with diagnoses including bilateral primary osteoarthritis of the knees and palliative care, and the MDS indicated moderately impaired cognition and a stage 4 pressure ulcer to the sacrum. The care plan directed licensed staff to cleanse the sacrum with normal saline, pat dry, apply hydrogel, and cover with a dry dressing. The TAR for two days was left blank for this treatment, and Treatment Nurse 1 stated the treatment nurses forgot to chart the treatment on those days. The DON stated pressure ulcer treatments should be documented on the TAR every time they are completed and that if the TAR was left unsigned, the treatment was not done. Resident 12 was admitted with diagnoses including history of falling, dysphagia, and dementia, and the MDS indicated severely impaired cognition. After a fall, the resident was transferred to an acute care hospital, and nursing notes documented that the licensed nurse received an order from the on-call physician to send the resident to the emergency room. However, the physician order summary did not contain an order for the transfer. The DON stated the transfer order should have been documented in a progress note and entered as a physician order, and the failure to do so made the order incomplete. For Resident 123, who was admitted with heart failure, acute respiratory failure, and palliative care, the H&P indicated the resident had capacity to understand and make decisions, and the MDS showed the resident was on oxygen therapy. The progress notes documented that the resident expired at 3:40 AM, but the weights and vitals summary recorded an oxygen saturation of 92% at 6:46 AM. The DON stated this documentation was inaccurate because the resident had already expired, and LVN 1 stated the entry should have been corrected.
Infection Control Lapses With Dirty Medication Tray and Improperly Stored Personal Care Items
Penalty
Summary
The facility failed to implement infection prevention and control practices when an LVN administered medications to two residents using a medication tray that was visibly soiled with dust and dirt and was not sanitized before use. Resident 63 was admitted with diagnoses including unilateral primary osteoarthritis of the left knee and hypertension, and the MDS indicated moderately impaired cognitive skills for daily decision making and varying levels of assistance with activities of daily living. Resident 87 was admitted with diagnoses including hypertensive urgency and hypertension, and the MDS indicated moderately impaired cognitive skills with assistance needed for eating, oral hygiene, dressing, toileting, showering, and lower body dressing. During the medication pass observation, LVN 3 placed Resident 87's medication cups on the dirty tray, LVN 2 took the tray into the resident's room and administered the medication, then returned to the cart and used the same tray to prepare Resident 63's medication without sanitizing it. During the concurrent interview, LVN 2 stated the tray had not been sanitized prior to administering medication to Residents 63 and 87 and acknowledged that bacteria on the tray could potentially cause illness. The IPN stated staff should ensure the medication tray was sanitized prior to giving medication to residents to prevent cross contamination and the spread of infections. The facility's policy stated contaminated medication trays shall be removed from service, cleaned, disinfected, and allowed to dry before reuse, and that disinfectant wipes should be used before and after each use. The facility also failed to properly label and store personal care items in shared bathrooms for two residents. Resident 51 had intact cognition and required maximal assistance from staff for oral hygiene, personal hygiene, and upper body dressing, while Resident 118 had intact cognition and required setup or clean-up assistance for oral hygiene, personal hygiene, and upper body dressing. During observation, three disposable razors belonging to Resident 51 were left on top of the sink in a shared bathroom, and Resident 118's orange toothbrush was also left on top of the sink in the shared bathroom. CNA 1 stated these items should have been placed in labeled wash basins and stored on the residents' dressers, and the DON stated personal care items such as razors and toothbrushes should be labeled and stored in a wash basin inside the resident's bedside dresser to avoid the spread of infection.
Resident Not Addressed by Proper Name
Penalty
Summary
The facility failed to ensure that Resident 12 was called by the resident's legal, proper, and preferred name. Resident 12 was admitted with diagnoses including a history of falling, dysphagia, and dementia. The MDS dated 3/23/2026 indicated the resident had severely impaired cognition and was dependent on staff to eat. A quarterly nutritional progress note dated 6/23/2026 stated the resident remained on the same diet, had a good appetite, and was a feeder. During an observation on 7/1/2026, Resident 12 was seen sitting upright in a wheelchair across from the nursing station. In an interview that day, RN 1 stated Resident 12 was a feeder and needed assistance with feeding during all meals. On 7/2/2026, the DON stated that a resident who required feeding assistance was referred to as a feeder, but also stated that it was inappropriate to call residents feeders because it was a dignity issue and could cause embarrassment. The facility's Dignity policy stated staff should speak respectfully to residents at all times, including addressing the resident by name of choice and not labeling or referring to the resident by room number, diagnosis, or care needs.
Advance Directive Not Readily Accessible in Resident Chart
Penalty
Summary
The facility failed to ensure that Resident 3’s advance directive was accessible to facility staff as required by the facility’s policy and procedure. Resident 3 was originally admitted on 7/12/2019 and later readmitted, with diagnoses including generalized osteoarthritis, anxiety disorder, and schizophrenia. The resident’s 3/20/2026 H&P stated the resident did not have the capacity to understand and make decisions, and the 4/17/2026 MDS indicated severely impaired cognitive skills for daily decision making, with substantial to maximal assistance needed for some ADLs and dependence for eating, oral and personal hygiene, toileting, bathing, and lower body dressing. During a record review on 6/30/2026, Resident 3’s medical chart did not contain an advance directive. On 7/2/2026, the SSD reviewed Resident 3’s advance directive dated 8/15/2019 and stated it had been obtained from MR staff and should be kept in the resident’s medical chart so it could be accessed by facility staff. MR staff stated the advance directive was kept in the medical records office and was not easily accessible to facility staff. The facility’s policy stated that advance directive documents are to be maintained in the resident’s medical record and readily retrievable by any facility staff in a prominent, accessible location.
Missing behavior documentation for antidepressant order
Penalty
Summary
The facility failed to ensure there was a manifestation-by (m/b) behavior documented for Sertraline ordered for one sampled resident. Resident 53 was admitted with diagnoses including psychosis, dementia, Alzheimer's disease, and depression. The resident's MDS dated 5/8/2026 indicated moderate cognitive impairment, partial assistance with eating and upper body dressing, substantial assistance with oral care, personal hygiene, showers, and lower body dressing, and dependence for toileting hygiene. A review of the resident's OSR dated 2/11/26 showed an order for Sertraline HCl 50 mg, 0.5 tablet by mouth daily for depression m/b, but the order did not specify the behaviors or symptoms supporting the antidepressant use. During interview, the DON stated the order did not include the m/b reason, nursing staff were monitoring the resident for depression, and staff should have clarified the order with the MD. The DON also stated there was no documentation that staff contacted the MD, and no progress notes or other documentation showed notification to the MD. LVN 1 stated antidepressant orders needed to specify the behaviors the resident was exhibiting and that staff should call the doctor to clarify when the m/b was missing.
PASRR Level I Screening Did Not Identify Schizophrenia
Penalty
Summary
The facility failed to accurately complete a Preadmission Screening and Resident Review Level I screening for one sampled resident with diagnoses including schizophrenia, anxiety disorder, and generalized osteoarthritis. The resident’s admission record showed an original admission on 7/12/2019 with a later readmission, and the history and physical dated 3/20/2026 indicated the resident did not have the capacity to understand and make decisions. The Minimum Data Set dated 4/17/2026 showed the resident’s cognitive skills for daily decision making were severely impaired and that the resident required substantial to maximal assistance with upper body dressing and was dependent for eating, oral and personal hygiene, toileting, bathing, and lower body dressing. During a concurrent interview and record review on 7/1/2026, the Assistant Administrator reviewed the resident’s PASRR I dated 1/6/2025 and found it indicated the resident was negative for SMI, ID/DD, or RC. Section III of the PASRR I stated the resident did not have a diagnosed SMI such as schizophrenia, even though the resident had a diagnosis of schizophrenia. The Assistant Administrator stated the resident had schizophrenia, which was a SMI, and that it was important to indicate the SMI on the PASRR I so the resident would be assessed for a PASRR II. The facility policy stated Level I screening screens every applicant for serious mental illness and that a Level II evaluation is required if the Level I screen is positive.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for Resident 12 after the resident sustained an unwitnessed fall on 3/11/2026. Resident 12’s admission record listed diagnoses including history of falling, dysphagia, and dementia, and the care plan dated 3/4/2026 identified the resident as being at risk for falls related to CVA. The accident/incident report dated 3/11/2026 at 12:13 a.m. stated the resident was found on the floor beside the bed, was assessed, and fall precautions were put in place. A transfer summary dated 3/11/2026 at 2:17 a.m. indicated the resident was transferred to an acute care hospital after the fall. The resident’s MDS dated 3/23/2026 indicated severely impaired cognition. During interview, RN 1 stated the resident had an unwitnessed fall and that the care plan was not updated after the fall, although it should have been. The DON stated that when a resident has a change in condition such as a fall, the care plan should be revised, and that revising the care plan after a fall is important to prevent further falls. The facility’s policy stated the interdisciplinary team would review and revise the comprehensive care plan after accidents, falls, pressure injuries, infections, weight changes, behavioral changes, or other clinically significant events.
Unlabeled Oxygen Tubing
Penalty
Summary
The facility failed to ensure that Resident 1’s nasal cannula oxygen tubing was labeled with the date and time in accordance with the facility’s oxygen administration policy. Resident 1 was admitted and re-admitted with diagnoses including pneumonitis, cardiomyopathy, and anemia. The resident’s H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS showed severely impaired cognitive skills for daily decision making, with dependence on staff for eating, toileting hygiene, and showering/bathing. During an observation in the resident’s room, the nasal cannula oxygen tubing did not have a label showing when it was last changed or replaced. An IPN observed the same condition and stated the tubing was supposed to be labeled in accordance with facility policy to prevent infection. The DON stated oxygen tubing should be labeled with date and time, and that the facility’s policy required oxygen supplies, including tubing, to be changed on the 15th and end of each month with the date and time documented.
Failure to Document Post-Dialysis Vital Signs
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident with end stage renal disease and heart failure who had an order for dialysis three times per week. The resident was cognitively intact and required assistance with some activities of daily living. Records showed the resident left the facility for dialysis and returned later the same day, and the facility documented that vital signs were checked before transport and at the dialysis center. During interview and record review, the RN stated that when the resident returned to the facility after dialysis, vital signs should have been checked and documented electronically, but the resident's record did not show that this occurred. The DON stated it was standard nursing practice to check vital signs before transport and again after the resident returned because blood pressure could drop after dialysis. The facility's dialysis policy also stated that post-dialysis nursing responsibilities included monitoring and documenting vital signs.
Failure to Implement Ordered Fall Prevention Measures and Post-Fall Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and its own policies for fall prevention. One resident admitted with respiratory and heart failure had a documented high fall risk score and a physician order for bilateral floor mats following a fall. Despite this, surveyors observed that the resident did not have bilateral floor mats at the bedside. The resident’s MDS and H&P showed intact cognition and a need for moderate to maximal assistance with ADLs. An LVN confirmed the resident had an order for bilateral floor mats due to a previous fall, stated that all residents with such orders should have mats at bedside, and acknowledged that the absence of mats created a risk of fall with injuries. Another resident with end-stage renal disease and peripheral vascular disease, who required varying levels of assistance with ADLs and had intact decision-making ability, also had an order for bilateral floor mats per the order summary report. During observation, this resident likewise did not have bilateral floor mats at the bedside. For two additional residents, records showed they had experienced falls, including one resident who sustained a forehead laceration. However, the facility did not complete post-fall risk assessments as required by its policies. One resident’s fall risk assessment documented a history of one or two falls and a moderate risk score, but this assessment was dated several weeks after the fall event. A fourth resident with hemiplegia and hemiparesis, intact cognition, and a need for assistance with multiple ADLs had a fall documented in an accident/incident report. The most recent fall risk assessment prior to that fall showed no history of falls and a moderate risk score, and there was no evidence of a fall risk assessment completed after the fall. The DON stated that fall risk assessments are to be completed on admission, quarterly, annually, and after a fall, and that residents at risk for falls are monitored and care planned with interventions. The DON also stated that residents must have floor mats if there is an order for them. Facility policies on fall risk assessment, assessing falls and their causes, and carrying out physician orders required review of fall history, completion of a fall risk assessment after a fall, documentation of appropriate interventions, and ensuring all physician orders are carried out safely and accurately, which did not occur for these residents.
Failure to Maintain Safe Oxygen Administration and Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate oxygen administration and infection prevention practices for three residents receiving oxygen therapy. For one resident with respiratory failure and heart failure, surveyors reviewed the admission record, history and physical, MDS, and oxygen orders, which showed the resident required supplemental oxygen at 2 L/min to maintain oxygen saturation above 91%. During observations in the resident’s room on two separate days, the resident’s nasal cannula was found not labeled with an open date and was touching the floor. In a concurrent interview, the Infection Preventionist Nurse (IPN) stated that nasal cannulas should be labeled with the date opened for infection prevention and acknowledged there was no way to know when or if the nasal cannula had been changed because it was not dated. For a second resident with end-stage renal disease and peripheral vascular disease, the order summary indicated an order for oxygen at 3 L/min to maintain oxygen saturation above 92%. The MAR directed staff to change and label oxygen tubing and the plastic bag every night shift starting on the last day of the month and ending on the last day of the month, but documentation from the beginning of the month through the survey date showed the oxygen tubing had not been changed. The resident’s electronic medical record did not contain a care plan for oxygen administration. During an observation and interview in the resident’s room, the resident did not have a bag at the bedside for oxygen equipment, and the nasal cannula was touching the floor. The IPN stated that residents required a bag for their oxygen equipment for infection control and that when residents were not using the nasal cannula, it must be placed in the bag to prevent contamination with germs. For a third resident with respiratory failure and dependence on supplemental oxygen, the order summary showed an order for oxygen at 2 L/min three times a day for shortness of breath. The MDS and history and physical indicated the resident had intact decision-making capacity and required varying levels of assistance with ADLs. During two separate observations, the resident was seen using a motorized wheelchair without receiving oxygen. In a record review and interview, the IPN interpreted the order for oxygen three times a day to mean the resident required continuous oxygen and that all three shifts had to monitor continuous oxygen use; the IPN stated the resident should not be without oxygen, even when using the motorized wheelchair. In a subsequent observation in the resident’s room, the nasal cannula was found hanging from the restroom doorknob and touching the floor. The IPN stated this was not acceptable practice because the nasal cannula had to be placed in a bag and not touch the floor, and that the cannula could not be reused because it was contaminated. The facility’s policy on oxygen administration/respiratory supply required all residents on oxygen to be monitored by nursing staff, all oxygen supplies to be changed biweekly with date and time documented, and all supplies not in use to be placed in a bag for infection prevention control. Additional interviews with the IPN and the DON confirmed the facility’s expectations and policies regarding oxygen equipment management and infection prevention. The IPN stated that for residents receiving oxygen, nursing staff must label nasal cannulas with the open date, place nasal cannulas in a bag when not in use, avoid allowing tubing to touch the floor, and change oxygen equipment weekly or biweekly. The IPN stated that not dating oxygen cannulas meant staff would not know if the equipment was old and that this could potentially cause an infection. The DON stated that residents on oxygen should have a care plan because oxygen administration is a lifesaving issue and that such a care plan would outline interventions such as checking pulse, following the physician’s oxygen order, placing oxygen tubing in a bag when not in use, and changing oxygen tubing every two weeks. The DON also stated that nursing staff were required to label oxygen equipment with the open date, change equipment every two weeks, and place unused equipment in a bag, and that all staff were responsible for ensuring infection prevention practices were followed and that residents were continuously receiving oxygen as ordered.
Failure to Follow Approved Menus and Notify Residents of Meal Changes
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure that meals were prepared and served according to the approved dietary menus for two consecutive lunch meals. On one day, residents were observed receiving meat, salad, and broccoli instead of the scheduled chicken cacciatore, garlic noodles, sautéed squash, French bread with margarine, and ice cream listed on the Spring Week Seven menu. On the following day, residents were served pizza and salad instead of the planned country fried steak with gravy, mashed potatoes, seasoned peas, and cherry cheesecake. These deviations from the planned menus occurred without adherence to the facility’s established menu and without documented, dietitian-reviewed substitutions. Interviews with the Dietary Services Supervisor (DSS) and the cook revealed that the DSS had provided menus and food spreadsheets to dietary staff and expected them to be followed for every meal, but the DSS did not verify that the correct menu items were prepared before food left the kitchen. The DSS stated they were present in the kitchen while the cook prepared meals but did not check what was being served and were not aware of the daily menu items for those days. The DSS acknowledged that they did not monitor dietary staff, did not ensure meals were served according to physician orders, and did not know what food was served on one of the days in question. The DSS also stated that residents were supposed to be notified of menu changes two to three hours before mealtime, but residents were not notified of the changes on either day. The cook reported that the chicken ordered for the scheduled meals did not arrive on time, and in response, the cook independently decided to serve pizza and other available items from the refrigerator instead of the planned menu items. The cook stated they did not notify the DSS of these changes, believed they were allowed to make menu changes without notifying the DSS, and admitted they had not reviewed the new menus received a month earlier, despite being expected to follow them that week. The DON stated that only the DSS and registered dietitians were authorized to make menu changes, that nursing staff must be informed so residents can be notified, and that residents did not receive the correct nutritional value because the dietary menu and food spreadsheets were not followed. Review of job descriptions and the facility’s “Menu Substitutions” policy confirmed that the Director of Food and Nutrition Services is responsible for supervising meal preparation according to established menus and that menu substitutions must be from the same food group as the omitted item, and that cooks are required to prepare food according to the facility menu and follow instructions from the DSS.
Failure to Provide Ordered Texture‑Modified Diets and Verify Food Consistency Before Service
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed texture‑modified diets and to ensure appropriate texture checks before food left the kitchen for two residents with ordered mechanically altered diets. For the first resident, who had respiratory failure and heart failure and was care planned for a therapeutic diet with monitoring for signs of swallowing difficulty, the clinical record showed an order and nutrition note for a mechanical soft/easy‑to‑chew diet. Despite this, surveyors observed the resident receiving meat and broccoli that were not in a mechanical soft consistency. The resident reported that meat was served in one piece and only cut into smaller pieces by staff, and that the broccoli was hard rather than soft, requiring prolonged chewing to swallow. On another observation, the resident was served grapes cut in half with skins on and melon cut in rectangular pieces, which the resident stated looked too large and declined to eat. The second resident had cerebrovascular disease, dysphagia, and vascular dementia with fluctuating decision‑making capacity, and was care planned for a therapeutic, mechanically altered diet with monitoring for pocketing, choking, coughing, drooling, and multiple swallowing attempts. The record documented an order for a minced and moist diet three times daily. However, surveyors observed this resident receiving a whole cheese sandwich with bread edges, apple pie with crust, and vegetable soup with bacon and carrots. The resident stated that the sandwich was cut into pieces by nursing staff but the pieces were still large and not easy to swallow, and that food provided was not easy to chew and was not cut into small pieces as needed for their condition. Staff interviews further described how these incorrect textures reached the residents. The Dietary Supervisor stated that a mechanical soft diet should consist of soft, easy‑to‑chew foods, with broccoli chopped into small pieces, and that a minced and moist diet required food to be wet, ground, and finely minced, with apple pie and bread edges not acceptable due to chewing difficulty. The facility’s policies for Level 7 Regular Easy to Chew and Level 5 Minced and Moist specified that meats should be chopped into 1/2‑inch or smaller or minced to 2–4 mm, moist, and cohesive, and that hard, sticky, or crunchy foods were excluded. The Dietary Supervisor acknowledged that dietary staff, including the supervisor, were responsible for checking food texture before trays left the kitchen. CNAs reported that sandwiches arrived whole from the kitchen and were cut by CNAs into bite‑size pieces without clear guidance on the required size, and that some items, such as pie, were too hard and needed further cutting. The DON stated that therapeutic diets were ordered for resident safety, that dietary staff were responsible for providing the correct texture, and that nursing staff were responsible for checking all residents’ food before delivery, underscoring that correct food texture was important to prevent choking.
Failure to Ensure Functioning Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure a working call light system for a sampled resident in their room and associated areas. The resident had cerebrovascular disease, dysphagia, and vascular dementia with fluctuating capacity, but was assessed on the MDS as having intact cognitive skills for daily decision-making and requiring varying levels of assistance for ADLs, including maximal assistance for showering/bathing and lower body dressing, and dependence for toileting hygiene and footwear. On two separate observations, when the resident pressed the call light in their room, the call light did not activate inside or outside the room, and the resident reported that staff did not come to assist when he used the call light and that he needed help with his lunch. Staff interviews confirmed expectations that all staff were responsible for answering and checking call lights, and that the call light system was the primary means for residents to communicate their need for assistance. An LVN stated that staff were responsible for ensuring call lights were working and that a functioning call light was important for resident communication and safety. A CNA reported that he checked residents’ call lights at the start of his shift and believed this resident’s call light was working, but when observed pressing the call light in the resident’s room, it again failed to activate, and the CNA acknowledged unawareness that it was not working and stated there was a potential for the resident not receiving needed assistance. The DON stated that maintenance was responsible for checking call lights and nursing staff were to check them every shift, and that if call lights were not working, residents’ needs would not be met. The facility’s call light policy indicated that call lights were to be answered within 5 to 6 minutes without undue delay.
Failure to Label IV and TPN Sites and Tubing per Policy
Penalty
Summary
The facility failed to adhere to professional standards of practice for infusion therapy in the care of two residents. For one resident with a history of gangrene and peripheral vascular disease, the peripheral intravenous (IV) site was not labeled with the date and initials upon insertion or dressing change, as required by facility policy. This omission was confirmed during observation and interview with nursing staff, who acknowledged that the labeling was necessary for infection control and to track when the dressing was last changed. The resident's care plan and facility policy both specified the need for dating and initialing the IV site dressing. For another resident receiving total parenteral nutrition (TPN) through a central venous catheter due to diagnoses including bladder cancer and anemia, the TPN administration set was not labeled with the date and time when it was hung. Observation and interviews with nursing staff and the DON confirmed that the tubing was unlabeled, contrary to facility policy, which required labeling to ensure proper infection control and to document when the tubing was last changed. Both deficiencies were identified through direct observation, record review, and staff interviews.
Failure to Maintain Safe and Sanitary Respiratory Care Practices
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents requiring oxygen therapy and related respiratory equipment. For one resident with pulmonary fibrosis and diabetes, observations revealed that both the oxygen tubing and nebulizer tubing were found on the floor, and a CNA confirmed that the tubing had become contaminated due to contact with the floor. The Director of Nursing (DON) acknowledged that such contamination poses an infection control risk, as equipment on the floor is considered contaminated and could be a source of infection for the resident. Another resident with a history of lung cancer, pneumonia, and chronic kidney disease was observed with oxygen nasal prongs not properly placed in the nostrils, and the nebulizer face mask was left on the bedside table instead of being stored in a clean bag. The DON and a nurse both stated that the nasal prongs should be in the nostrils to ensure the resident receives the prescribed oxygen, and the nebulizer mask should be stored in a clean bag to prevent contamination. Additionally, a resident with asthma and hypertension was found to be receiving oxygen therapy without the required "Oxygen No Smoking, No Open Flames" sign posted outside the room, contrary to facility policy and staff statements regarding fire safety. A further observation involved a resident with diabetes and chronic kidney disease, where the nasal cannula was found on the floor with the prongs directly touching the surface. Nursing staff confirmed that the cannula should be stored in a plastic bag when not in use to prevent cross-contamination. The facility's policy and procedure on oxygen administration and respiratory supply require that all supplies not in use be placed in a bag for infection control, and that appropriate signage be posted when oxygen is in use. These deficiencies were identified through direct observation, staff interviews, and review of facility records and policies.
Failure to Follow Bedrail Assessment and Consent Procedures
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of bedrails for two residents. For one resident with dementia, Alzheimer's disease, and moderately impaired cognition, full bedrails were observed in use without any documented assessment for safety risk, physician's order, or informed consent prior to installation. The resident was dependent on staff for most activities of daily living, and staff confirmed that the required assessment and documentation were not completed before applying the bedrails. For another resident with anxiety disorder and muscle weakness, both upper side rails were found raised, and the resident reported never being asked for consent regarding their use. The resident had intact cognitive skills and required some assistance with daily activities. Facility staff, including the DON, confirmed that no alternatives were attempted, no physician's order was obtained, and no informed consent was documented before the bedrails were installed. The facility's policy required assessment, consideration of alternatives, and consent prior to bedrail use, but these steps were not followed for either resident.
Medications Administered Outside Prescribed Time Window
Penalty
Summary
A deficiency occurred when a licensed vocational nurse administered five scheduled medications to a resident through a gastrostomy tube earlier than the prescribed time. The medications, which included Tylenol Extra Strength, Ferrous Sulfate Liquid, Folic Acid, Sertraline, and Docusate Sodium, were all scheduled for 9:00 a.m. but were given at 7:45 a.m. The nurse acknowledged that administering medications outside the scheduled time could affect their effectiveness. The facility's policy allows for medications to be given within one hour before or after the scheduled time, but this administration was outside that window. The resident involved had significant medical needs, including paraplegia, depression, dementia with severely impaired cognition, and was dependent on staff for all activities of daily living. The resident received nutrition via a feeding tube. The Director of Nursing confirmed that medications should be administered within the specified time frame to ensure therapeutic effectiveness and avoid potential harm, as outlined in the facility's policy.
Medication Error Rate Exceeded Due to Early Administration
Penalty
Summary
The facility failed to maintain a medication error rate at or below five percent during medication administration for one resident. On the observed date, a licensed vocational nurse administered five medications via gastrostomy tube to a resident with severe cognitive impairment, paraplegia, depression, and dementia. All five medications were scheduled for administration at 9 a.m., but the nurse administered them at 7:45 a.m., which was earlier than the prescribed time. The nurse acknowledged that administering medications outside the scheduled time could affect their effectiveness and that it was important to follow the correct timing to prevent medication errors. A review of the resident's records confirmed the resident's dependence on staff for all activities of daily living and the use of a feeding tube for nutrition. The facility's policy required adherence to the five rights of medication administration, including the right time. The Director of Nursing confirmed that medications should be given within one hour before or after the scheduled time and that deviations could result in medication errors. This incident resulted in five medication errors out of twenty-eight opportunities, leading to a medication error rate of 17.86%.
Failure to Secure Medications and Improper Resident Medication Storage
Penalty
Summary
Surveyors observed that a medication cart containing residents' medications was left unlocked and unattended in a hallway by a Licensed Vocational Nurse (LVN) during a medication pass. The LVN admitted to not locking the cart when retrieving medication from the medication room, acknowledging that the cart should have been secured for safety. The Director of Nursing (DON) confirmed that the medication cart needed to be locked if it was outside the licensed nurse's view. Facility policy and procedure documents reviewed by surveyors also required absolute security of medications, including locking medication carts when out of sight. Additionally, a resident with diagnoses including hypertension, depression, and chronic obstructive pulmonary disease (COPD) was found to have a prescribed inhalation medication stored in their bedside drawer. The resident stated they kept their medication in the drawer, and the LVN confirmed this, stating that medications should not be kept at the bedside for safety reasons. The DON stated that residents were not allowed to have medication at their bedside unless they had been assessed for safe self-administration. Facility policy required written physician orders and interdisciplinary committee determination for residents to self-administer or retain medications in their rooms.
Deficient Food Handling and Storage Practices Identified
Penalty
Summary
The facility failed to maintain safe food handling practices in several areas, as observed during a survey. Two out of four red sanitization buckets used in the kitchen were not maintained at the correct chemical concentration, as required by the manufacturer's guidelines of 200-400 ppm. Additionally, the log for checking the sanitizer concentration showed that the required check at 8:00 a.m. was not performed. The Dietary Supervisor confirmed that these buckets are used to sanitize kitchen surfaces. Further deficiencies were observed in food storage and labeling. One plastic container of expired red tomato salsa and one container of green salsa, both past their use-by dates, were found in the walk-in refrigerator. In the dry storage area, an open bag of penne pasta noodles and an open bag of spaghetti pasta noodles were not labeled with an open date or use-by date. The facility's policies require that leftover or opened foods be labeled and dated to ensure proper use and safety. The Dietary Supervisor acknowledged the importance of these practices to prevent serving expired or unsafe food.
Failure to Implement and Communicate Infection Control Precautions
Penalty
Summary
The facility failed to implement and follow infection prevention and control procedures for multiple residents requiring isolation or enhanced barrier precautions (EBP). For one resident with a Stage 3 pressure injury, there was no EBP signage or isolation cart with personal protective equipment (PPE) outside the room, despite physician orders and care plan interventions requiring these measures. The Infection Prevention Nurse confirmed that signage and PPE carts should have been present to ensure staff compliance with EBP protocols. Another resident with a gastrostomy tube and severely impaired cognition was observed receiving medication administration from an LVN who did not don a gown, as required under EBP. The LVN acknowledged the omission and stated that a gown should have been worn to prevent cross-contamination. Additionally, a resident with a biliary drain and central line did not have EBP signage posted outside the room, despite orders and facility policy indicating that such signage is necessary to communicate required precautions to staff and visitors. Further deficiencies included a disposable gown left hanging on the doorknob inside the room of a resident on contact isolation for a multidrug-resistant organism (MDRO), contrary to facility policy that requires immediate disposal of used gowns. The facility also lacked a water management program with a diagram or text assessing where Legionella or other waterborne pathogens could grow, as required by their own policy. These failures were confirmed through staff interviews and review of facility policies and procedures.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
Staff failed to promote dignity while assisting a resident with meals by not feeding the resident at eye level to maintain face-to-face contact. The resident, who had diagnoses including Parkinson's disease, dementia, and diabetes mellitus, was admitted with severely impaired cognition and required total assistance with eating. During an observation, a CNA was seen standing over the resident while providing feeding assistance, rather than sitting at eye level as required by facility policy and best practices for maintaining resident dignity. Interviews with the CNA and the DON confirmed that staff are expected to feed residents at eye level to allow for proper monitoring and to uphold the resident's dignity. The facility's policy on meal assistance specifically states that residents should not be fed while staff are standing over them, emphasizing the importance of safety, comfort, and dignity during mealtimes. The failure to follow this policy was directly observed and acknowledged by staff.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with hemiplegia affecting the right dominant side, muscle weakness, and anxiety was found with their call light on the floor and out of reach. The resident's care plan specified that the call light should be kept within reach, particularly on the side of the resident's strong arm and hand. During observation, the resident was lying in bed with a contracted right hand, and the call light was not accessible. Certified Nurse Assistant 3 confirmed that the resident could not reach the call light and acknowledged it should have been placed within reach of the resident's functional side. Further review of the resident's records indicated that the resident was dependent on staff for activities of daily living and had intact cognition. The facility's policy and procedures required that call lights be kept within reach of residents at all times. The Director of Nursing also stated that the call light should be placed close to the resident's good arm and hand to ensure timely response to needs. The failure to keep the call light within reach was contrary to both the care plan and facility policy.
Failure to Maintain Advance Directive Documentation in Resident Record
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive (AD) and AD Acknowledgement Form were present in the medical record for one of three sampled residents. Upon review of the resident's admission record, it was found that the resident, who had a history of malignant neoplasm of the lung, pneumonia, and chronic kidney disease, did not have a copy of the AD or the AD acknowledgement form in either the paper chart or the electronic medical record. The resident's Minimum Data Set indicated moderately impaired cognition and a high level of dependence on staff for daily activities. Interviews with the RN Supervisor and the DON confirmed that the AD and AD acknowledgement form should be updated and included in the resident's chart with each admission or readmission. The facility's policy also required that residents be provided with information about their rights regarding medical treatment and advance directives upon admission, and that this information be prominently displayed in the medical record. The absence of these documents in the resident's record was verified during the survey process.
Failure to Complete Required Background Check Prior to Hire
Penalty
Summary
The facility failed to conduct a required background check for one of two randomly selected employees, a Certified Nurse Assistant (CNA), prior to hire as mandated by the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy. During a review of the CNA's employee file, there was no documented evidence that the Office of Inspector General (OIG) database check or any background check was completed before or after the CNA's hiring date. Interviews with the Director of Staff and Development and the Director of Nursing confirmed that background checks are necessary for staff and resident safety, and that the administrator was responsible for performing these checks prior to employment. The facility's policy requires that no individual with a history of abuse, neglect, exploitation, or misappropriation be employed, but this process was not followed in this instance.
Foley Catheter Tubing Not Secured as Required by Facility Policy
Penalty
Summary
A deficiency was identified when a resident with a Foley catheter was observed with the catheter tubing not secured to the thigh, contrary to the facility's policy and procedure. The resident, who had diagnoses including type 2 diabetes mellitus, hypertension, and chronic kidney disease, was dependent on staff for most activities of daily living and required an indwelling Foley catheter for urinary retention and skin management. The care plan specified that staff should monitor the position of the catheter tubing to ensure proper urine flow, and the order summary required licensed staff to check every shift that the catheter was in place. During observation and interviews, it was confirmed by both a registered nurse and the Director of Nursing that the catheter tubing was not secured as required, and the securement device was not taped. The facility's policy indicated that the tubing should be attached to the resident's leg to prevent pulling and injury. This failure to follow established procedures had the potential to result in catheter-related complications for the resident.
Failure to Prevent Biliary Drainage Leak and Maintain Infection Control
Penalty
Summary
A deficiency occurred when a resident with a biliary drain was found to have biliary fluid on the floor beneath their drainage bag. The resident, who had diagnoses including bladder cancer and anemia, required substantial to maximal assistance for mobility and had an order in place to monitor and document biliary drain output three times daily. Documentation showed the drain output was being recorded, but during an observation, yellow liquid from the biliary drain was seen on the floor. The LVN present confirmed that each nurse is responsible for emptying the drainage bag during their shift and acknowledged that the drainage should not be leaking onto the floor. The Director of Nursing confirmed that biliary fluid should not be present on the floor due to infection control concerns, as organisms in the fluid could be a source of illness or infection and could be transmitted by contact. The facility's policy on biliary drain management emphasized the importance of proper care to prevent infection and ensure appropriate drainage. The failure to prevent biliary drainage from leaking onto the floor constituted a lapse in infection control practices for the resident requiring biliary drain care.
Failure to Act on Pharmacist's Medication Regimen Review Recommendation
Penalty
Summary
The facility failed to act upon a consultant pharmacist's medication regimen review (MRR) recommendation for a resident who was receiving Enoxaparin Sodium Injection (Lovenox) for deep vein thrombosis prophylaxis. The pharmacist's MRR specifically recommended that a duration of therapy be provided for the use of Lovenox. However, there was no documentation that the attending physician was notified of this recommendation, as confirmed by both a Licensed Vocational Nurse and the Director of Nursing during interviews and record reviews. The resident involved had a medical history including osteomyelitis, diabetes mellitus, and chronic obstructive pulmonary disease, and required varying levels of assistance with activities of daily living. The facility's policy and procedure required that the consultant pharmacist's findings and recommendations be reported to the physician and documented accordingly, but this process was not followed in this instance. As a result, the pharmacist's recommendation regarding the medication regimen was not communicated or acted upon.
Failure to Follow Antibiotic Stewardship Policy for UTI Treatment
Penalty
Summary
The facility failed to implement its policy on antibiotic use and change in condition for one of five sampled residents, resulting in the administration of antibiotics without meeting established criteria. A resident with diagnoses including Alzheimer's disease, dementia, and depression was admitted and later had an abnormal urinalysis. Subsequently, a physician ordered Cephalexin for a urinary tract infection, and the medication was administered for ten days. However, the resident's medical record did not document any of the required signs or symptoms of a symptomatic UTI as outlined in the facility's Infection Criteria Checklist, and there was no urinary catheter in place. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that the necessary documentation of UTI signs and symptoms was not present in the resident's record. Both staff members acknowledged the importance of completing infection criteria and tracking to ensure appropriate antibiotic use and compliance with the facility's Antibiotic Stewardship Program. Review of facility policies indicated that changes in resident condition and antibiotic use should be thoroughly documented and tracked, but these procedures were not followed in this case.
Failure to Adhere to Hand Hygiene Protocols for C. diff Isolation
Penalty
Summary
The facility failed to implement its Policy and Procedure (P&P) on Handwashing and Hand Hygiene, specifically in the case of a certified nursing assistant (CNA 1) who did not wash their hands after interacting with a resident diagnosed with Clostridium difficile (C. diff) infection. This resident, identified as Resident 3, was admitted with end-stage renal disease and enterocolitis due to C. diff. The care plan for Resident 3 included contact isolation precautions to prevent the spread of infection, which required staff to adhere to strict hand hygiene protocols. During an observation, CNA 1 was seen moving Resident 3's overbed table and adjusting bed linens without washing their hands afterward. Despite removing their isolation gown and gloves, CNA 1 exited the room without performing hand hygiene, only washing their hands at the nurses' station sink. This action was contrary to the facility's P&P, which mandates handwashing with soap and water after contact with residents with infectious diarrhea, such as C. diff, before exiting the isolation room. Interviews with other CNAs and the Infection Prevention Nurse (IPN) confirmed the necessity of handwashing before exiting the room of a resident on contact isolation. The IPN emphasized that handwashing with soap and water is recommended over alcohol-based hand sanitizers to prevent the spread of C. diff. The facility's P&P on Handwashing and Hand Hygiene clearly outlines these procedures, highlighting the importance of hand hygiene as a primary means to prevent infection spread.
Failure to Implement Smoking Policy and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents who were smokers. Resident 8, who was on Seroquel for paranoid schizophrenia and had a history of hearing voices telling him to harm himself and others, was found to have cigarettes and lighters in his room. He smoked unsupervised, contrary to the facility's smoking policy, which required staff supervision due to his mental health condition. The Director of Nursing (DON) was unaware of Resident 8's possession of smoking materials and confirmed that he had not been evaluated for safe smoking practices. Resident 36, who had poor vision and was legally blind, also had cigarettes and lighters in her possession and smoked without supervision. Her care plan indicated she required supervision due to her impaired vision and the presence of an oxygen machine in her room, which posed a significant fire hazard. Despite these risks, Resident 36 was allowed to keep smoking materials and was not monitored during smoking, as required by her care plan and the facility's smoking policy. The facility's failure to implement its smoking policy and ensure proper supervision of these residents created a potential for serious harm, including fire hazards, due to the presence of smoking materials in the residents' rooms. The survey team identified these deficiencies during their investigation, highlighting the facility's noncompliance with safety protocols for residents who smoke.
Removal Plan
- Cigarettes and cigarette lighters were removed from Resident 8 and Resident 36's rooms and placed under supervision of the charge nurses (Licensed Vocational Nurses [LVNs] and Registered Nurses [RNs]).
- Resident 8 and Resident 36's CPs were updated by LVNs and the DON.
- Resident 8 and Resident 36 were educated by the facility's DON on smoking and cigarette lighter safety and why cigarette lighters cannot be in residents' possession.
- Resident 8 was informed by the ADM for safety and importance of using appropriate and approved ashtrays for cigarette butts (the part of the cigarette that was left after it had been smoked).
- The Supervised Designated Smoking Area Map for smokers was created which included the following: a. Patio in front of the facility by the front entrance. b. Patio outside the facility by the back entrance/parking lot. c. Patio outside the facility exit located between rooms [ROOM NUMBERS].
- The Designated Smoking Time Schedule for residents who required smoking supervision was created which included the following: a. Morning after breakfast from: 8:00 am to 8:30 am, 9:00 am to 9:30 am and 11:30 am to 12:00 pm b. Afternoon after lunch from: 1:00 pm to 1:30 pm, 2:30 pm to 3:00 pm and 4:30 pm to 5:00 pm c. Evening after dinner from: 6:00 pm to 6:30 pm
- The Director of Staff Development (DSD) provided an in-service to 26 Certified Nursing Assistants (CNAs), nine LVNs, four RNs, one Social Services Designee, one Medical Records Designee, three activity staff, and one housekeeper on the facility's revised smoking policies regarding supervised smoking, designated smoking areas, and designated smoking time schedules.
Deficient Food Handling and Storage Practices
Penalty
Summary
The facility failed to maintain safe food handling practices, specifically in the storage and sanitation of an ice scoop and its container. The ice scoop was stored in a container that contained approximately 100 milliliters of a brown liquid substance, which the scoop was in contact with. This contaminated scoop was used by Certified Nursing Assistants (CNAs) to fill ice chests that were distributed to the North and South Nursing Stations, affecting 42 out of 90 residents who received ice during breakfast and lunch. The facility had no records of cleaning and sanitizing the ice scooper container as per their policy. Additionally, the facility did not ensure safe food storage practices. In one of the kitchen freezers, food items were not dated when received, and mixed salad dressings were not discarded after their indicated shelf life. In the kitchen's dry and canned storage area, food items were also not dated, and in one of the unit refrigerators, stored food items were not labeled with the resident's name and date. These practices placed residents at risk for food-borne illnesses. The survey team identified an Immediate Jeopardy situation due to the facility's failure to meet food safety standards, specifically regarding the storage of food equipment in a sanitary condition. The ice scoop and container were not cleaned and sanitized daily, as required by the facility's policy. This oversight led to the distribution of contaminated ice to residents, posing a risk of water-borne illnesses.
Removal Plan
- The ice scoop and ice scoop container were placed in the kitchen dishwasher to be cleaned and sanitized.
- The two ice chests in the north and south nursing stations were sanitized.
- The ice machine located in the facility's dining room was locked and put into temporary out of service.
- All residents' water pitchers and cups for 90 residents (total census) were replaced with new/uncontaminated water pitchers and cups.
- The Dietary Supervisor (DS) in-serviced four dietary aides on the cleaning of the ice scooper and ice scooper container.
- 200 pounds of ice was purchased by the ADM.
- A new ice scooper and container sanitation log was created for the dietary aides on duty to log in the time of the day when they sanitize the ice scooper and the ice scooper container. The DS would check the log to ensure the ice scooper and the ice scooper container were sanitized daily.
- A water company service had been contracted and scheduled maintenance of the ice machine and replacement of water filter every six months.
- The facility's (P&P) titled, Cleaning and Sanitizing the Ice Scooper and Container for Ice Machine, was revised to include daily cleaning of the ice scooper, the ice scooper container and document in the cleaning log.
- A new clear ice scooper container with lid and new ice scooper was purchased.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to transmit assessments within 14 days of completion for 23 sampled residents. This deficiency was identified during a review of the Minimum Data Set (MDS) 3.0 Final Validation Report, which showed that the assessments for these residents were submitted late. The MDS Nurse indicated that the Assistant Administrator (AADM) was responsible for transmitting the MDS assessments to the Centers for Medicare and Medicaid Services (CMS). However, the AADM admitted to not realizing the due dates for these assessments, resulting in the delay. The AADM further acknowledged that the facility had not provided training to other MDS staff on how to transmit MDS assessments to CMS. The facility's policy and procedure, which was undated, stated that MDS staff were responsible for timely transmission of MDS data in accordance with the MDS RAI Instruction Manual. The failure to transmit these assessments on time had the potential to result in inaccurate information being submitted to CMS, which could affect the facility's star rating and quality of care.
Deficiencies in Gastrostomy Tube Care
Penalty
Summary
The facility failed to provide necessary care and services for gastrostomy tube (GT) management for two residents, leading to potential risks of infection and adverse consequences. For Resident 193, who was admitted with diagnoses including subdural hemorrhage and epilepsy, the GT tubing was observed with the end open and hanging on a pole, contrary to the care plan that required it to be capped to prevent infection. This was confirmed by interviews with the Licensed Vocational Nurse, Registered Nurse Supervisor, and Director of Nursing, all of whom acknowledged the need for the tubing to be covered to maintain the quality of the feeding formula and prevent contamination. Similarly, for Resident 195, who had diagnoses including senile degeneration of the brain and altered mental status, the GT site was found without a cover or dressing, despite the care plan's requirement for daily cleaning and dressing to prevent infection and skin irritation. The Infection Preventionist Nurse and Director of Nursing confirmed that the site should be covered as ordered to protect the skin and prevent accidental pulling during movement. The facility's policy on enteral feedings also emphasized the importance of securing the tube and applying a new dressing as per physician orders.
Deficiency in Oxygen Therapy Management
Penalty
Summary
The facility failed to provide necessary care and services for residents on oxygen therapy as ordered by the physician, as indicated in the residents' plan of care and in accordance with the facility's Policy and Procedure on Oxygen Administration. This deficiency was observed in four residents who were receiving oxygen therapy. The facility did not label the oxygen tubing with the date it was changed or started, which is crucial for infection control and ensuring the tubing is changed on schedule. This oversight was noted in the cases of Residents 189, 31, and 2, where the oxygen tubing lacked proper labeling, potentially leading to bacterial growth and infection. Resident 189, admitted with conditions including hypertension and morbid obesity, was observed with oxygen tubing that was not labeled with the date of change. Similarly, Resident 31, who had diagnoses including congestive heart failure and respiratory failure, also had unlabeled oxygen tubing. Interviews with the Registered Nurse Supervisor and the Infection Preventionist Nurse confirmed the necessity of labeling the tubing to prevent infection. Resident 2, diagnosed with chronic obstructive pulmonary disease, had an oxygen concentrator with coiled tubing in a plastic bag, also lacking a date label, which was acknowledged by the Registered Nurse Supervisor as a risk for bacterial growth. Additionally, Resident 64, who was dependent on supplemental oxygen due to chronic respiratory failure, was found with nasal prongs improperly positioned under the chin, rather than in the nostrils, during an observation. This improper placement meant the resident was not receiving the prescribed amount of oxygen. The Registered Nurse Supervisor admitted to not checking the proper placement of the nasal prongs during rounds. The facility's policy indicated that nasal cannula should be properly positioned and monitored by licensed nurses, which was not adhered to in this instance.
Lack of Dialysis Emergency Kits for Residents
Penalty
Summary
The facility failed to ensure that a dialysis emergency kit was readily available for two residents who required dialysis services. Resident 85, who was admitted with diagnoses including diabetes mellitus and dependence on renal dialysis, was observed without a dialysis emergency kit at their bedside. The Treatment Nurse confirmed the absence of the kit, which is essential for controlling bleeding at the dialysis access site in an emergency. This oversight placed Resident 85 at risk for excessive bleeding, which could lead to serious harm or death. Similarly, Resident 44, admitted with end-stage renal disease and dependence on renal dialysis, also lacked a dialysis emergency kit at their bedside. The Registered Nurse Supervisor confirmed the absence of the kit, emphasizing its importance in managing potential bleeding emergencies. The Director of Nursing later acknowledged that the facility did not have policies and procedures in place to ensure the availability of dialysis emergency kits at the bedside, further contributing to the deficiency.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information reflecting the actual hours worked by both licensed and unlicensed nursing staff responsible for resident care per shift. This deficiency was observed during a recertification survey, where it was noted that the staffing information was not posted in a prominent location for two out of four days. Specifically, the staffing information was found inside the North Nurses' Station, and no information was posted in the South Nurse's Station, making it inaccessible to residents, family, and visitors. During interviews, the Director of Staff Development (DSD) admitted to projecting the actual hours worked by nursing staff and was unaware that the information needed to be posted in a location accessible to residents, family, and visitors. The facility's policy and procedures indicated that staffing information should be posted in a prominent location within two hours of the beginning of each shift. The DSD acknowledged that the current posting location inside the North Nurses' Station was not accessible to those outside the station, which could mislead residents and visitors about the staffing levels available for resident care.
Failure to Implement GDR and Limit PRN Orders for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that five residents on psychotropic drugs were free from unnecessary medication. Specifically, the facility did not attempt a Gradual Dose Reduction (GDR) for two residents and did not limit PRN orders for psychotropic medications to 14 days for three residents. These practices had the potential to lead to inappropriate use of psychotropic drugs, affecting the residents' physical, emotional, and psychosocial well-being. Resident 25, admitted under hospice care for end-stage Alzheimer's disease, was prescribed Seroquel and Haloperidol for agitation. Despite only two episodes of agitation being recorded, there was no documented attempt at GDR for Seroquel, nor was there an evaluation for the continued use of Haloperidol beyond 14 days. The Director of Nursing acknowledged the oversight in following up on the discontinuation of these medications. Resident 47, with severe cognitive impairment, had been on a consistent dose of Seroquel since 2022 without any documented GDR attempts, despite minimal behavior incidents. Additionally, Residents 13, 41, and 77 had PRN orders for antianxiety medications that exceeded the 14-day limit without reevaluation by a physician. The facility's policy required PRN orders for antipsychotic medications to be reassessed every 14 days, which was not adhered to in these cases.
Inadequate Infection Control and Water Safety Management
Penalty
Summary
The facility failed to establish a comprehensive infection prevention and control program, specifically in monitoring and managing water safety to prevent the growth of Legionella and other waterborne pathogens. During interviews, the Administrator admitted that the facility did not monitor water management, as they believed there were no stagnant waters, and acknowledged the absence of preventative measures for Legionella. The Infection Preventionist Nurse confirmed that although the facility had a policy for Legionella surveillance and detection, there were no implementations for such surveillance. The facility's policy indicated that all pneumonia cases diagnosed 48 hours after admission should be investigated for Legionnaire's disease, but this was not being followed. Additionally, the facility failed to adhere to Enhanced Barrier Precautions (EBP) for a resident with a Foley catheter, which increased the risk of infection. The resident's care plan required continuous monitoring, signage on the door, and proper PPE usage to prevent cross-infection. However, observations revealed that there was no EBP signage posted outside the resident's room, nor was there a PPE cart provided. Interviews with the Registered Nurse Supervisor and the Infection Preventionist Nurse confirmed that these precautions were necessary and should have been in place to prevent the spread of infection.
Failure to Include Advance Directive in Resident's Medical Chart
Penalty
Summary
The facility failed to adhere to its policy on Advance Directives (AD) by not ensuring a current copy of a resident's AD was included in the medical chart. This deficiency was identified for one of the sampled residents, who was admitted with diagnoses including a urinary tract infection, hyperlipidemia, and constipation. The resident was alert and oriented, with intact cognitive abilities, and had both an AD and a Physician Orders for Life Sustaining Treatment (POLST) form. However, during a review, it was found that the AD was not present in the resident's medical chart, only the POLST was available. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed that the facility's policy required the AD to be prominently displayed in the medical record. The SSD acknowledged that the ADPA form was not specific enough to indicate whether the resident had an AD or a POLST, which could lead to the resident's wishes not being respected if the AD differed from the POLST. The DON confirmed that the absence of the AD in the medical chart posed a risk of not honoring the resident's wishes. The facility's policy stated that information about the existence of an AD should be prominently displayed in the medical record, which was not followed in this case.
Privacy Breach During Bed Bath
Penalty
Summary
The facility failed to maintain privacy for Resident 28 during a bed bath, which was observed by surveyors. Resident 28, who was admitted with diagnoses of dementia and epilepsy, had moderately impaired cognition and required assistance with personal care. During the bed bath, Certified Nursing Assistant 6 (CNA 6) did not adequately cover Resident 28's body, leaving the resident exposed while washing different areas. The privacy curtain was left open, and another CNA entered the room, further compromising Resident 28's privacy. The facility's policy and procedure for giving a bed bath were not followed by CNA 6. The policy required washing one part of the body at a time, covering each area after washing, and changing the bath water as necessary. However, CNA 6 used the same water for washing different parts of Resident 28's body and did not cover the resident appropriately, leading to exposure. This lack of adherence to the facility's procedures resulted in a deficiency related to maintaining the privacy and dignity of Resident 28.
Failure to Implement Translation Services for LEP Resident
Penalty
Summary
The facility failed to implement its policy and procedure on Translation and Interpretation services for a resident with limited English proficiency (LEP). The resident, who was admitted with a wedge compression fracture, unspecified hearing loss, and a history of falling, had the capacity to understand and make decisions. The resident's preferred language was Chinese, as indicated in the Minimum Data Set. However, during an observation, the resident called out in Spanish, and the Licensed Vocational Nurse (LVN) communicated by pointing to body parts, which did not ensure the resident understood the purpose of the medication being administered. There was no communication board at the bedside to facilitate communication in a language the resident could understand. The Activities Director (AD) confirmed that the facility had communication boards in Spanish, Arabic, Filipino, and Mandarin, which were supposed to be at the bedside for residents who could not communicate in English. The AD stated that without these boards, residents' needs would not be met. The facility's policy indicated that individuals with LEP should have meaningful access to information and services, and that their needs and questions should be accurately communicated to the staff. The failure to provide appropriate communication tools for the resident with LEP had the potential to result in unmet needs.
Failure to Respond to Call Light in a Timely Manner
Penalty
Summary
The facility failed to respond to a call light and provide timely assistance to a resident, identified as Resident 289, who required help with activities of daily living. Resident 289 was admitted with a history of falling and a wedge compression fracture of the first lumbar vertebra. The resident's care plan indicated the need for assistance, and the Minimum Data Set assessment confirmed the requirement for maximal assistance with sitting on the side of the bed and moderate assistance with sit-to-stand and toilet transfers. Despite these needs, the resident's call light was observed to be on for 31 minutes without a response, during which time the resident expressed the need for help to use the restroom. Interviews with facility staff, including a Certified Nursing Assistant and a Registered Nurse Supervisor, revealed that the facility's policy required call lights to be answered within five to six minutes. Both staff members acknowledged that a 30-minute wait was unacceptable and posed a risk of the resident attempting to get up unassisted, potentially leading to a fall or injury. The facility's policy and procedure on call light response were not adhered to, resulting in a deficiency in providing timely care and assistance to Resident 289.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Covina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harvard Creek Post Acute | 0.5 mi | ★★★★★ | 22 | 0 |
| Covina Rehabilitation Center | 0.8 mi | ★★★★★ | 17 | 0 |
| Emanate Health Inter-community Hospital- D/p Snf | 1 mi | ★★★★★ | 9 | 0 |
| Clara Baldwin Stocker Home For Women | 2 mi | ★★★★★ | 25 | 0 |
| Glendora Grand, Inc | 2.2 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.