Valley Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bakersfield, California.
- Location
- 1205 8th Street, Bakersfield, California 93304
- CMS Provider Number
- 555229
- Inspections on file
- 56
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Valley Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain a functional call system in both shower rooms, where one shower room lacked any call system and the other had a wireless call button that did not activate an alarm at the nurses station. The MS confirmed there was no working call system in these areas and acknowledged that replacement wireless buttons frequently went missing. The DON stated that the shower room call systems had been nonfunctional as an ongoing issue and confirmed that two residents using the toilet in one shower room were at high risk for falls, with one resident having a high Morse Fall Scale score and another having severe cognitive impairment and a high fall risk score. One resident reported independently using the toilet in the shower room and confirmed there was no call system available, despite facility policy requiring call systems in toileting and bathing areas and designating bathroom call bells as emergency calls.
The facility failed to develop and implement required care plans for three residents. One resident with mobility limitations and a right foot amputation was documented as preparing and using marijuana in his room, staying in his car all night blocking the entrance, and continuing to drive despite an unresolved surgical wound, yet no care plan addressed his substance use or driving. Another resident left the facility with an ex‑spouse and did not return for several days, and there was no care plan for this pattern of non‑compliance or leaving without informing staff. A third resident was receiving Cresemba per MD orders, but no care plan addressed this antifungal medication therapy. These omissions occurred despite a facility policy requiring comprehensive, person‑centered care plans based on assessed needs.
A cognitively intact resident with significant mobility limitations and a healing surgical foot wound repeatedly left the facility and drove a personal vehicle without a physician out-on-pass order, without notifying licensed staff, and without required nursing assessments before leaving or upon return, despite a facility policy mandating physician authorization, nurse assessment, and proper sign-out/sign-in. In a separate case, a resident with a GT and documented skin irritation around the GT site did not receive GT site care every shift as ordered by the physician, the dressing was observed to be soiled, not covering the insertion site, and leaking formula, CNAs did not report the condition to licensed staff, and no care plan was developed to address the GT-related skin irritation, contrary to the facility’s wound management policy requiring ongoing skin assessment and care planning.
The facility did not submit the results of an investigation into an allegation of resident-to-resident abuse to CDPH within the required five-day period, instead providing the report ten days after the incident, contrary to facility policy.
A deficiency was cited for not ensuring a safe, clean, comfortable, and homelike environment for a resident, including the safe provision of treatment and daily living supports.
A resident dependent on a G-tube and at risk for dehydration did not receive physician-ordered water flushes or documented hydration, despite a dietician's recommendation. Staff failed to obtain necessary orders, communicate recommendations, and monitor intake and output as required, resulting in the resident being hospitalized for sepsis, hypernatremia, and severe dehydration.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The QAPI committee did not identify or document non-functional restroom call lights, resulting in an unsafe environment for all residents. The Medical Director, Administrator, and Maintenance Supervisor were unaware of the issue, and facility records did not reflect any monitoring or corrective action regarding the call light system.
Surveyors found that call light systems in all resident bathrooms and shower rooms were non-functional or inaccessible, preventing residents from alerting staff for assistance while using these areas. Facility policy required operational call systems, but none were working or properly placed at the time of the survey.
Surveyors observed two medication carts left unsecured and unattended, with one cart's drawers unlocked and accessible, and a jar of Lactulose left on top of another cart while a nurse administered medications to a resident. The DON was unable to secure the cart's locking mechanism, and staff acknowledged the lapse in medication security, contrary to facility policy.
Three dietary staff did not follow CDC-recommended handwashing procedures, applying soap before wetting their hands and not adhering to the correct sequence. The facility's hand hygiene policy and posted instructions also did not match CDC guidelines. Additionally, the facility lacked a written inventory for PPE, relying on visual checks by the Supplies Supervisor rather than documented tracking.
A review of facility documentation and resident assignments revealed that 23 rooms did not provide the required 80 square feet per resident in multiple occupancy rooms, with some rooms offering as little as 66 to 77 square feet per resident. The Administrator confirmed the deficiency, and no residents were found to be negatively affected at the time of the survey.
A resident's diet was changed from regular to pureed at the request of the resident, but the responsible party was not notified of this change. The DON confirmed that nurses could downgrade diet consistency without physician notification, but there was no documentation that the responsible party was informed, contrary to facility policy.
Two residents receiving dialysis did not receive complete nursing assessments as required, with missing pain and respiratory assessments before and after dialysis sessions. Facility policy mandates such monitoring and documentation, but staff interviews and record reviews confirmed these steps were not followed.
Surveyors found that the kitchen's two compartment sink, used for washing produce and food, lacked an air gap for backflow prevention. Staff confirmed the absence of an air gap, and dietary staff were observed washing fresh strawberries in the sink. The facility did not have a policy addressing air gaps, and the Director of Maintenance stated it was not possible to create one in the current setup.
The facility failed to develop and implement care plans for two residents at high risk for falls, leading to potential accidents and injuries. One resident had a high fall risk score but no care plan, while another experienced two falls with injuries before a care plan was initiated. The facility's policy requires individualized care plans based on fall risk assessments, which was not followed.
The facility failed to notify the MDs of two residents and the RP of one resident about abuse allegations, as required by its Abuse Prevention and Prohibition Program policy. The DON and Administrator confirmed the absence of documentation in the residents' medical records, which should have been recorded in a progress note.
The facility failed to consistently implement care plans for two residents, leading to potential unmet psychosocial and physical needs. Despite allegations of abuse and neglect, the required psychosocial monitoring was not documented consistently over a 72-hour period, as confirmed by the DON.
The facility failed to provide reasonable access to a telephone that ensured privacy for three residents. Staff and residents confirmed that phone calls had to be made in non-private areas like the Administrator's office or the nursing station, and the facility lacked portable phones. This issue was acknowledged by multiple staff members and contradicted the facility's policy on telephone access.
A resident admitted with hemiplegia and reduced mobility was not assessed for pressure injury risk, and their left heel redness was not reported to a physician or treated. No care plan or IDT meeting was conducted, leading to the development of a Stage 3 pressure injury.
The facility failed to ensure accurate medical records for a resident, as confirmed by the DON. The resident's Wound Weekly Observation Tool indicated an SDTI, while the care plan incorrectly documented it as a stage 3 pressure injury. The facility's policy mandates accurate and chronological documentation, which was not followed in this case.
The facility failed to follow their policy on contacting APS when a resident with multiple health issues and moderate cognitive impairment left AMA. The resident's responsible party was not contacted, and arrangements for continued dialysis were not made.
The facility failed to ensure that air mattresses for three residents were set correctly according to their weights, leading to potential safety risks. Observations and interviews revealed that neither the nurses nor the maintenance worker were trained or responsible for setting the correct air mattress settings, and the facility lacked policies for such training.
A facility failed to provide oxygen per physician's orders for a resident with COPD, pneumonia, and respiratory failure. The resident was observed receiving oxygen at six liters per minute instead of the prescribed two liters per minute, contrary to the facility's policy and procedure for oxygen administration.
The facility failed to provide proper foot care for two residents, resulting in pain and discomfort. LVNs did not perform adequate skin assessments or develop care plans, and CNAs failed to report and document observations. The podiatrist did not provide appropriate treatment, leading to neglected foot conditions.
The facility failed to complete activity assessments for 16 residents within the required seven days of admission, as confirmed by the Activity Director. This oversight could impact the residents' physical, mental, and psychosocial well-being.
The facility failed to ensure staff competencies for five sampled Licensed Nursing Staff, including three RNs and two LVNs. Interviews revealed that a Certified Wound Nurse did not receive on-the-job training, and the Director of Nursing admitted that no competency assessments were being conducted. The Director of Staff Development confirmed the absence of documented skills competency assessments, and the Administrator-in-Training stated that no performance evaluations had been conducted for the current nursing staff.
The facility failed to maintain kitchen sanitation, properly store and label food, ensure staff followed dress code policies, and serve food in a sanitary manner. Observations included a dirty ladder and scaffolding in the kitchen, unsealed and unlabeled food items, and staff with uncovered facial hair. Additionally, a Dietary Supervisor returned a plated portion of food to the serving line, which was deemed inappropriate.
The facility failed to ensure proper infection control practices for residents, including not wearing PPE, not performing hand hygiene, and not addressing bowel movement leakage. Staff also mishandled trash and laundry without proper hygiene, and the infection preventionist did not maintain records of surveillance activities or properly stock isolation carts.
The facility failed to ensure accurate records of Influenza and Pneumonia vaccinations for all residents. The Infection Control Preventionist could not provide vaccination records for 11 residents and could not verify pneumonia vaccination status for 40 residents. Only seven residents had signed declination statements, and the facility lacked a policy for these vaccinations.
The facility failed to ensure the Infection Preventionist (IP) maintained accurate records of employee COVID-19 vaccinations for 110 of 159 employees. The IP did not have a log of vaccinations and only had 49 vaccination cards on file. The IP admitted to requesting the cards verbally but did not follow up, resulting in incomplete records.
The facility failed to ensure that five licensed nurses were trained to meet the behavioral health requirements of 29 residents. No competency assessments or specific training for psychological or mental disorders were conducted, leaving staff unprepared to address residents' behavioral health needs.
The facility failed to ensure timely completion of MDS assessments for three residents. Quarterly and annual assessments were either not transmitted or still in progress, contrary to the facility's policy and procedures. This was confirmed during interviews and record reviews with the MDS Coordinator.
The facility failed to ensure that the Pharmacy Consultant conducted Medication Regimen Reviews (MRR) for two residents on psychotropic medications and did not perform monthly medication reviews for all 71 residents. The absence of these reviews was confirmed by the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON).
The facility failed to ensure that two residents had access to a call light, which had the potential for unmet care needs. One resident's call light was found on the floor, and another's was hanging on the wall behind the headboard, both out of reach. Staff acknowledged that the call lights should have been within the residents' reach.
The facility failed to notify the responsible party of a resident's change in condition, despite the resident lacking the capacity to make their own decisions. The resident had a skin tear, and the responsible party was not informed, contrary to the facility's policy.
The facility failed to obtain proper authorization for a resident's transfer, allowing a cognitively impaired resident to sign documents despite a physician's certification of incapacity. The responsible party was not notified, leading to confusion and potential risk.
The facility failed to develop and implement care plans for two residents, leading to potential negative outcomes. One resident repeatedly refused medical care without a specific care plan in place, and another resident did not have a care plan developed after a fall, contrary to the facility's policies.
The facility failed to provide preventive measures for pressure injuries for a resident with quadriplegia and did not ensure weekly wound assessments for two residents. The lack of a pressure-relieving mattress and appropriate dressings, along with inadequate repositioning, contributed to skin breakdown. Additionally, required weekly wound assessments and documentation were not completed, hindering the monitoring of wound healing progress.
The facility failed to assess five residents for bed entrapment risk before applying bedrails, despite having a policy requiring such assessments. The Maintenance Supervisor and Minimum Data Set Coordinator confirmed that no assessments or documentation had been completed.
The facility failed to ensure an RN was scheduled and on duty for eight hours a day, seven days a week. A review of the nursing staffing schedule for October, November, and December 2023 revealed multiple dates where no RN was on duty for the required hours. The facility's policy required an adequate number of nursing personnel, including at least one RN in the facility at all times for facilities licensed for 60 to 99 beds, in addition to the DON.
The facility failed to maintain a medication error rate below five percent, with two errors occurring in 29 opportunities. A nurse did not administer a resident's blood-thinning medication, and another nurse did not provide an inhaler for COPD due to unavailability. The DON stated that nurses should call the pharmacy in advance to prevent running out of medications.
The facility failed to ensure the safe administration of medication for a resident when an albuterol inhaler was found on the bedside table. Two LVNs acknowledged the oversight, which violated the facility's policy requiring secure storage of medications.
The facility failed to assess and update a resident's food preferences, leading to dissatisfaction with the food served. The Dietary Supervisor had not reviewed the resident's preferences since admission, contrary to facility policy.
A resident with cerebral infarction, hemiplegia, hemiparesis, and dysphagia was given a mechanical soft diet instead of the prescribed pureed diet with nectar thick liquids. The CNA and CDM admitted to the error, which was against the facility's policy requiring adherence to physician-prescribed diet orders.
The facility failed to provide a language-assistance service for a resident who spoke a language native to the Punjab region of Pakistan. CNAs used Google Translate to communicate, as the facility lacked a formal translation service, leading to frustration and unmet care needs. The Administrator-in-Training admitted the facility did not have a translation service and relied on calling staff at home or contacting the Ombudsman for translation needs.
The facility failed to provide a summary of the Baseline Care Plan (BCP) within 48 hours of admission for four residents, leading to incomplete or missing care plans. This included residents with serious conditions such as Type 2 Diabetes Mellitus, Hemiplegia, Metabolic Encephalopathy, Sepsis, Unspecified Dementia, and Mood Disorder.
The facility failed to administer Percocet according to the physician's order for a resident, administering it for pain levels of 5 and 6 instead of the prescribed severe pain levels of 7-10. The DON confirmed this discrepancy during an interview and record review.
The facility failed to notify an MD of a resident's extremely high blood pressure and did not conduct IDT meetings for the resident's new wound issues. The DON and TN confirmed these lapses, which are against the facility's policy and procedure.
The facility failed to complete fall risk assessments for two residents. One resident did not have an assessment on admission despite having conditions like lack of coordination and reduced mobility. Another resident who fell did not have a quarterly or post-fall risk assessment completed.
Failure to Maintain Functional Call System in Shower Rooms
Penalty
Summary
The facility failed to ensure that a functional call system was available in resident bathrooms and bathing areas, specifically in both shower rooms at station 2 and station 3. During an observation and interview in the station 3 shower room with the Maintenance Supervisor (MS), surveyors noted there was no call system present for residents using the toilet or shower. The MS confirmed there was no call system available and stated there should have been an alternative call system provided for residents in these areas. In the station 2 shower room, a black wireless call button with a bell logo was observed hanging on the handrail next to the toilet. When the MS pressed this button and then went to nurses station 1, no alarm was heard, and the MS acknowledged that an alarm should have sounded to alert staff that assistance was needed in the shower room. The MS reported that he would replace the black wireless call buttons in the shower rooms but that these buttons would go missing, and reiterated that there should have been a functional call system available for residents using the toilet and shower. The DON stated that the facility had two shower rooms (station 2 and station 3) and that the call system in these shower rooms had not been working, describing it as an ongoing issue. The DON confirmed that residents using the toilet in the station 3 shower room, including Resident 85 and Resident 14, were at risk for falls and that the absence of a call system in the shower rooms would put residents at risk for accidents and falls. Resident 85’s Morse Fall Scale (MFS), dated 12/9/25, showed a score of 55, indicating high fall risk, and Resident 14’s MDS showed a BIMS score of 6, indicating severe cognitive impairment, with an MFS score of 60. Resident 14 reported independently using the toilet in the station 3 shower room and stated there was no call system there. The facility’s policy titled “Communication – Call System” required the facility to provide a call system in resident rooms and toileting/bathing facilities and identified bathroom call bells as emergency calls that must be answered promptly.
Failure to Develop and Implement Care Plans for Substance Use, Non‑Compliance, and Antifungal Therapy
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for three residents, as required by its care planning policy. For one resident with a BIMS score indicating intact cognition, documented functional limitations in range of motion, wheelchair dependence, and a right foot amputation, multiple behavior notes and staff interviews showed that he prepared and used marijuana in his room, stayed in his car all night blocking the entrance while playing loud music, and continued to drive his car despite his amputation and an unresolved surgical wound. The Social Services Director and DON confirmed that the resident had been seen using marijuana, had nearly hit several cars in the parking lot, and that there was no care plan addressing his use of illegal substances or his driving, with the DON stating the facility did not know how to keep him safe when driving and acknowledging that the care planning policy was not followed. A second resident left the facility with an ex‑spouse and did not return for several days, and the Social Services Director confirmed there was no care plan addressing this resident’s pattern of non‑compliance or leaving the facility without informing staff. For a third resident, record review showed an active physician order for Cresemba, an anti‑fungal (anti‑viral/fungal) medication, but the Infection Prevention Nurse was unable to provide evidence of any care plan developed and implemented to address this medication therapy. The facility’s written care planning policy, which requires a comprehensive person‑centered care plan for each resident based on assessed needs, including services required and any services not provided due to exercise of resident rights, was not followed in these cases.
Failure to Follow Out-on-Pass and GT Wound Management Policies
Penalty
Summary
The deficiency involves the facility’s failure to follow its “Out on Pass” policy for a cognitively intact resident with significant physical limitations and an unresolved surgical wound. The resident’s MDS showed a BIMS score of 13, functional limitations in range of motion on one side of both upper and lower extremities, wheelchair dependence, inability to walk, and a need for supervision or touching assistance with transfers and setup assistance for wheelchair mobility. A medical progress note documented a history of need for assistance with personal care and generalized muscle weakness, with comments indicating a need for supervision and care 24 hours a day. The resident reported having all toes amputated on the right foot, with a healing surgical wound, and was observed with a dry dressing wrapped around the right foot. Record review showed that the resident purchased a vehicle and was leaving the facility without a physician out-on-pass order. The order summary report confirmed there was no physician order for out on pass. The facility’s out-on-pass log for the month showed multiple instances where the resident signed out but did not sign back in on return. Staff interviews revealed that the resident had been seen using marijuana in the facility and driving his car, with the social services director stating the resident had almost hit several cars in the parking lot. The DON and social services director both stated the resident would leave without notifying licensed nurses, preventing timely notification of the physician, and the DON confirmed the resident did not have a physician order to go out on pass. Further review of nursing notes showed that on one occasion the morning nurse reported the resident had signed out in the afternoon, was seen leaving during rounds, and had not returned by the time of the evening medication pass, with a later note documenting the resident’s return. The DON stated the resident was not assessed by a licensed nurse prior to leaving or upon returning to the facility, despite the facility’s written policy requiring a licensed nurse to assess the resident’s physical and mental status before leaving and to reassess upon return. The DON acknowledged that the policy, which also requires a physician order for passes and verbal notification to a licensed nurse before leaving, was not followed. The deficiency also includes the facility’s failure to follow its wound management policy and physician orders for treatment of a resident’s gastrostomy tube (GT) site. On admission, nursing documentation indicated the resident had a GT with skin irritation. The physician’s order summary directed staff to cleanse the GT site with normal saline, pat dry, apply zinc oxide to the peri-wound area, cover with a T-drain sponge, and secure with tape every shift. However, the treatment administration record showed the ordered treatment was only being performed on the day and evening shifts, not every shift as ordered. The treatment nurse confirmed the order was not followed and that there was no physician order to monitor the GT site as needed. During observation, the resident’s GT dressing was black, did not cover the insertion site, and the GT site was red and leaking yellow liquid. The treatment nurse stated the dressing was wet from leaking GT formula and that the moisture was causing irritation and redness around the site, and also stated the GT site should have been monitored as needed to keep it clean and dry. A CNA reported seeing the resident earlier with a black dressing that did not cover the GT site and acknowledged she did not notify the treatment nurse or any licensed nurse, stating she should have done so. Review of the care plan showed there was no care plan developed to address the skin irritation at the GT site, despite the DON stating the irritation was caused by leaking GT formula and that there should have been a care plan to monitor when the dressing needed to be changed. The facility’s wound management policy required a licensed nurse to perform skin assessments and develop a care plan based on physician recommendations, and the DON stated this policy was not followed.
Failure to Timely Report Investigation Results of Abuse Allegation
Penalty
Summary
The facility failed to report the results of an investigation into an allegation of resident-to-resident abuse to the California Department of Public Health (CDPH) within the required five-day timeframe. According to the SOC 341 form, the facility became aware of the abuse allegation involving two residents and reported the initial incident to CDPH the following day. However, although the facility completed its investigative report, it did not submit the results to CDPH until ten days after the incident. The facility's own policy and procedures require that the state survey agent receive a copy of the investigative report within five days of the incident.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the facility's failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that this includes, but is not limited to, receiving treatment and supports for daily living in a safe manner. Specific actions or inactions leading to this deficiency are not detailed in the provided report excerpt, nor are there direct observations or events described.
Failure to Provide and Document Hydration for G-Tube Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on a gastrostomy tube (G-tube) for nutrition and hydration, and had an order for nothing by mouth (NPO), did not receive appropriate hydration management during their stay. The resident was identified as being at risk for dehydration, with a high score on the Dehydration Risk Screener. Despite this, there was no physician's order for water hydration or flushes, and no documentation that hydration was provided. The Registered Dietician (RD) recommended water flushes of 150 cc every six hours, but this recommendation was not communicated to the physician, not documented in the clinical record, and not implemented by nursing staff. The facility's staff, including the Licensed Vocational Nurse (LVN), Certified Dietary Manager (CDM), and RD, failed to ensure that the RD's hydration recommendation was followed. The LVN did not obtain a physician's order for water flushes, and both the LVN and CDM failed to document the RD's recommendation. The RD did not follow up within the expected timeframe to confirm that her recommendation was implemented. Additionally, the facility did not monitor or record the resident's intake and output (I&O) as required by facility policy for residents with feeding tubes. As a result of these failures, the resident did not receive documented water hydration during their five-day stay and was subsequently transferred to an acute care hospital with diagnoses of sepsis, hypernatremia, and severe dehydration. Facility policies required assessment and implementation of nutrition and hydration programs, as well as monitoring of I&O for residents receiving enteral feedings, but these were not followed in this case.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Identify and Address Non-Functional Restroom Call Lights
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify, document, and correct a deficiency related to the physical environment, specifically the non-functional resident restroom call light system. During interviews and record reviews, it was revealed that the Medical Director, who participated in the QA committee, was unaware of any restroom call light deficits, despite acknowledging that nonfunctional call lights posed a safety concern. The facility's assessment tool and QAPI binder did not reflect any issues with the call light system, and there was no documentation indicating that the restroom call lights were not working. The Administrator confirmed that there was no record of the restroom call lights being nonfunctional, and the Maintenance Supervisor stated that there was no documentation of call light checks and was unaware of the issue. The facility's assessment tool and quality assurance policy both referenced the importance of maintaining the physical environment and communication systems, including call lights, for resident safety. However, the lack of monitoring and documentation led to the ongoing deficiency, affecting all 85 residents in the facility.
Non-Functioning Call Light Systems in Resident Bathrooms and Shower Rooms
Penalty
Summary
The facility failed to ensure that operational call light systems were available and accessible in all resident bathrooms and shower rooms. During an observation and interview with the Maintenance Supervisor, it was found that none of the bathroom call light systems in the facility were functioning. When activated, the call lights in multiple resident bathrooms and shower rooms did not trigger any visual or auditory alarms outside the rooms or at the nurse's station. In some cases, call lights were not accessible to residents using the toilet or shower, and in certain bathrooms and shower rooms, no call light system was present at all. Facility policy and procedure documents indicated that the Maintenance Department was responsible for maintaining all mechanical, electrical, and patient care equipment in safe operating condition, and that the facility was to provide a call system to enable residents to alert nursing staff from their rooms and toileting/bathing facilities. Despite these policies, the lack of functioning call light systems in 18 resident bathrooms and three shower rooms meant that all 85 residents potentially could not call for help if they required assistance while using these areas.
Failure to Secure Medication Carts and Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were securely stored and labeled in accordance with professional standards, as required by its own policy and procedure. During an early morning observation, Medication Cart 2 was found unattended and unlocked in a hallway near the nurse's station, with all drawers except the controlled medication drawer accessible. The Director of Nursing was present and able to open the unlocked drawers, and was unable to secure the cart's locking mechanism. The Director acknowledged that the unlocked cart could allow residents to access medications. In a separate incident, a registered nurse prepared medications for a resident, including Lactulose, and left the medication jar unattended on top of Medication Cart 1 while administering medications in a resident's room. The nurse later stated that she usually does not leave medications unattended on the cart. Review of the facility's policy confirmed that medications are to be stored safely and securely, accessible only to authorized personnel. These observations demonstrate a failure to follow established procedures for medication security.
Hand Hygiene and PPE Inventory Deficiencies
Penalty
Summary
Three dietary staff members failed to follow proper handwashing procedures as outlined by CDC guidelines. Specifically, each staff member applied soap to their hands before wetting them under running water, contrary to the recommended sequence of wetting hands first, then applying soap, lathering, scrubbing for at least 20 seconds, rinsing, and drying. The facility's posted handwashing instructions and its written policy and procedure on hand hygiene did not align with CDC guidelines, omitting the correct order and steps for effective hand hygiene. These observations were confirmed during interviews and a review of the facility's policies. Additionally, the facility did not maintain a written inventory of its personal protective equipment (PPE) such as gowns, gloves, masks, goggles, and face shields. Instead, the Supplies Supervisor monitored PPE stock visually and ordered more supplies when it appeared that inventory was running low. The facility's policy stated that appropriate PPE should be available at all times, but there was no documentation or record-keeping to ensure this requirement was consistently met.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that 23 out of 34 resident rooms met the required minimum of 80 square feet per resident in multiple occupancy rooms, as determined by a review of the Client Accommodations Analysis and the Resident List Report. Specific room measurements and resident assignments showed that several rooms provided less than the required space per resident, with some rooms offering as little as 66 to 77 square feet per resident in double occupancy, and 70 to 75 square feet per resident in triple occupancy. The Administrator confirmed during an interview that these rooms did not meet the 80 square feet per resident requirement. No residents in the affected rooms were identified as having experienced negative effects due to the insufficient room size at the time of the survey. The facility's policy and procedure for Maintenance Services indicated that the Maintenance Department is responsible for maintaining the building in compliance with federal, state, and local regulations, but the documented room sizes and resident assignments did not meet these regulatory requirements.
Failure to Notify Responsible Party of Diet Change
Penalty
Summary
The facility failed to notify the responsible party (RP) when a resident's diet texture was changed from regular to pureed. The responsible party became aware of the change only after the resident mentioned over the phone that she was being fed 'baby food.' The Director of Nursing (DON) confirmed that the resident had requested a pureed diet after observing another resident eating it, and that nurses were permitted to downgrade diet consistency without informing the physician. However, there was no documentation in the nurse's notes indicating that the responsible party had been informed of this change. A review of the resident's physician orders showed that the prescribed diet was regular with thin consistency, and the progress notes documented the change to pureed. The facility's policy required timely notification of residents, families, legal representatives, and physicians regarding changes in a resident's condition. Despite this policy, the responsible party was not informed of the change in diet consistency, as confirmed by the DON.
Failure to Complete Required Assessments for Dialysis Residents
Penalty
Summary
The facility failed to complete required nursing assessments for two residents receiving dialysis services. For one resident, the Nursing Dialysis Communication Record (NDCR) showed that a pain assessment was not performed after dialysis, which was confirmed by a registered nurse who stated that such an assessment was important for early identification of complications. For the second resident, the NDCR indicated that a respiratory assessment was not completed before dialysis, and a pain assessment was not performed after dialysis. The registered nurse acknowledged that these assessments should have been conducted as part of the resident's care. Review of the facility's policy and procedure for dialysis care revealed that the facility is responsible for monitoring residents before and after each dialysis treatment and for maintaining all related documentation in the medical record. The Director of Nursing confirmed that the policy was not followed in these instances, resulting in incomplete assessments and documentation for both residents who required dialysis services.
Lack of Air Gap in Kitchen Food Preparation Sink
Penalty
Summary
The facility failed to ensure that the two compartment sink in the kitchen, which was used for washing produce and food for residents, was equipped with an air gap as required for backflow prevention. During multiple observations, it was noted that the sink lacked an air gap, and dietary staff were seen washing fresh strawberries in this sink. Both the Consultant Dietary Services Manager and the Director of Maintenance confirmed during interviews that the sink did not have an air gap, and the Director of Maintenance stated that it was not possible to create one in the current setup. Additionally, the facility did not have a policy or procedure addressing air gaps for sinks used in food preparation. A review of the FDA Food Code and the facility's own maintenance policy highlighted the requirement for backflow prevention devices such as air gaps to prevent contamination of the water supply. The absence of an air gap in the food preparation sink created a situation where contaminated water could potentially flow back into the clean water supply, posing a risk to food safety. The deficiency was identified through direct observation, staff interviews, and review of relevant policies and regulations.
Failure to Implement Fall Risk Care Plans for High-Risk Residents
Penalty
Summary
The facility failed to develop and implement care plans for two residents who were at high risk for falls, leading to potential accidents and injuries. Resident 1's Fall Risk Assessment (FRA) dated 11/28/24 indicated a high fall risk score of 45, yet no fall risk care plan was noted in the clinical record. The Director of Nursing (DON) confirmed the absence of a fall risk care plan for Resident 1 during a review of the FRA. Resident 2's FRA dated 4/3/24 showed a high fall risk score of 60. Despite this, Resident 2 experienced two falls, on 6/21/24 and 7/12/24, resulting in injuries such as an abrasion on the mid-back, bruising to the left thumb, and a skin tear on the right lower arm. The DON confirmed that a fall risk care plan was only initiated on 7/15/24, after these incidents. The facility's policy requires the development of individualized care plans based on fall risk assessments, which was not adhered to in these cases.
Failure to Notify MDs and RP of Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse Prevention and Prohibition Program policy and procedure when it did not notify the medical doctors (MD) of two residents and the responsible party (RP) of one resident regarding allegations of abuse. Specifically, the Director of Nursing (DON) confirmed that there was no documentation indicating that the MDs of two residents and the RP of one resident were informed about the abuse allegations. This lack of documentation was acknowledged during a review of the residents' medical records and confirmed by the DON and the Administrator. The facility's policy, revised on January 31, 2020, mandates that the attending physician and responsible party, if applicable, be notified of any allegations and the outcome of the investigation. However, the facility did not adhere to this policy, as evidenced by the absence of documentation in the medical records of the involved residents. The Administrator confirmed that such notifications should be documented in a progress note, but this was not done, leading to a deficiency in the facility's abuse prevention and reporting procedures.
Inconsistent Implementation of Care Plans for Residents
Penalty
Summary
The facility failed to consistently implement care plans for two residents, leading to potential unmet psychosocial and physical needs. An interview with the Director of Nursing (DON) revealed that management received an email from a former employee alleging abuse against three residents. Registered Nurse (RN) 1 stated that for allegations of abuse, a care plan for delayed injury and psychosocial outcomes would be created and monitored for 72 hours. However, upon reviewing the care plans for two residents, it was found that the intervention to monitor psychosocial well-being for 72 hours was not consistently documented. The care plans for the residents were initiated following alleged incidents of physical abuse and neglect. Despite the facility's policy and procedure indicating that care plans should address medical, nursing, mental, and psychosocial needs, the documentation of psychosocial monitoring was inconsistent. The DON confirmed during a record review that the required monitoring was not documented consistently over the 72-hour period for the two residents involved.
Lack of Private Telephone Access for Residents
Penalty
Summary
The facility failed to provide reasonable access to a telephone that ensured privacy for three sampled residents. Interviews with staff and residents revealed that residents had to use the phone in the Administrator's office, the facility main office phone, or the nursing station, none of which provided privacy. The facility lacked portable phones, making it difficult for residents to have private conversations. This issue was confirmed by multiple staff members, including Licensed Vocational Nurses and Certified Nursing Assistants, who acknowledged the lack of private phone access for residents. Resident 1, who was cognitively intact, expressed concerns about the inability to have private conversations. Resident 2, with moderate cognitive impairment, also confirmed the lack of privacy for phone calls. The Administrator in Training admitted that the facility had no portable phones since June 2023, and calls were either made at the nursing station or through staff members' cell phones. The facility's policy on telephone access, dated November 1, 2017, stated that residents should have access to private phone lines, but this was not being followed.
Failure to Implement Pressure Ulcer Prevention Policy
Penalty
Summary
The facility failed to implement its policy and procedure for pressure ulcer prevention for a resident who was admitted with diagnoses including hemiplegia, hemiparesis, muscle weakness, and reduced mobility. Upon admission, the resident was not assessed for the risk of developing pressure injuries as the Braden Scale for Predicting Pressure Sore Risk was left blank. This oversight was confirmed by the Director of Nursing (DON) during a record review. Additionally, the resident's left heel redness, noted one day after admission, was not reported to the physician, and no treatment was documented in the Treatment Administration Record (TAR). The DON confirmed that the physician was not notified to obtain treatment for the left heel redness. Furthermore, the facility did not develop a care plan to address the resident's left heel redness, as confirmed by the DON during a record review. The resident's condition worsened over time, with the left heel redness progressing to a suspected deep tissue injury (SDTI) and eventually to a Stage 3 pressure injury. The resident reported that the wound care provider had been treating the wound, which prevented the resident from being discharged. The Treatment Nurse (TN) stated that the facility's process for new admissions with wounds was not followed, as the necessary steps such as measuring the wounds, contacting the physician, developing a care plan, and performing weekly wound assessments were not completed. Additionally, the facility failed to conduct an interdisciplinary team (IDT) meeting to address the resident's left heel redness. The DON confirmed that no IDT meeting was held in March 2024 to discuss the resident's condition. The facility's policy and procedure for pressure ulcer prevention, which includes risk identification, assessment, care planning, and ongoing monitoring, were not adhered to, resulting in the resident developing a Stage 3 pressure injury to the left heel.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the accuracy of medical records for one of the three sampled residents. During an interview and record review, the Director of Nursing (DON) confirmed that the medical record for a resident contained inaccurate information. Specifically, the Wound Weekly Observation Tool (WWOT) dated 4/4/24 indicated that the resident had a suspected deep tissue injury (SDTI) to the left heel, while the care plan incorrectly documented it as a stage 3 pressure injury. The care plan was initiated on 4/4/24, but the interventions were noted to have started on 4/3/24, one day before the care plan initiation. The DON acknowledged that the documentation was not accurate. The facility's policy and procedure (P&P) on Completion & Correction, revised on 5/1/19, mandates that medical records should be completed and corrected in a standardized manner to ensure the highest quality and accuracy in documentation. The P&P specifies that entries should be recorded promptly, be complete, legible, descriptive, and accurate, and should follow a chronological sequence. The policy also states that events should never be documented before they occur. The failure to adhere to these guidelines resulted in the inaccurate documentation of the resident's medical condition.
Failure to Notify APS for Resident Leaving AMA
Penalty
Summary
The facility failed to follow their policy and procedure on contacting Adult Protective Services (APS) when a resident left the facility against medical advice (AMA). The resident, who had a diagnosis of metabolic encephalopathy, muscle weakness, alcohol abuse and withdrawal, hemiparesis/hemiplegia, noncompliance with medication, and end-stage renal disease, signed himself out of the facility. Despite the resident's moderate cognitive impairment and periods of confusion, as indicated by his Minimum Data Set (MDS) and History and Physical Examination (H&P), the facility did not notify APS as required by their policy. The resident was not his own responsible party, contrary to the administrator's initial statement, and arrangements for his continued dialysis were not made. The Social Services Director (SSD) confirmed that attempts to contact the resident's family member, who was listed as the responsible party and emergency contact, were unsuccessful. The SSD also confirmed that APS was not notified of the resident's AMA discharge, which was a violation of the facility's policy and procedure titled 'Discharge Against Medical Advice.'
Failure to Ensure Safe Air Mattress Settings
Penalty
Summary
The facility failed to ensure that air mattresses for three residents were in safe operating condition. During observations and interviews, it was found that the air mattress settings for Resident 1, Resident 2, and Resident 3 were incorrectly set at 290 lbs, 350 lbs, and 1000 lbs, respectively, despite their actual weights being 110 lbs, 158 lbs, and 448 lbs. Licensed Vocational Nurse (LVN) 1 and the Treatment Nurse (TN) were unaware of how to properly set up the air mattresses, and the Facility Maintenance Worker (FMW) believed that the nurses were responsible for setting the correct settings. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that no training had been provided to the nurses on how to set up the air mattresses according to resident weight. The lack of training and clear responsibility for setting up air mattresses led to improper settings that could potentially harm the residents. The facility's Licensed Nurse List indicated that none of the 28 nurses had received training on air mattress setup. Additionally, the facility did not have any policies or procedures in place for licensed nurse training and competencies related to air mattress settings. This deficiency in training and policy had the potential to impact the safety and well-being of the residents using air mattresses for pressure relief and wound prevention.
Failure to Administer Oxygen Per Physician's Orders
Penalty
Summary
The facility failed to provide oxygen per physician's orders for one of three sampled residents. During an observation and interview, a Licensed Vocational Nurse (LVN) noted that a resident was receiving oxygen at six liters per minute via nasal cannula, while the physician's order specified two liters per minute. The resident had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), pneumonia, and respiratory failure. The facility's policy and procedure for oxygen administration required checking the physician's order and setting the oxygen at the prescribed rate, which was not followed in this instance.
Neglect of Foot Care for Two Residents
Penalty
Summary
The facility failed to ensure proper foot care for two residents, resulting in pain, discomfort, and neglect. Licensed Vocational Nurses (LVNs) did not perform adequate skin assessments, develop care plans for foot conditions, or notify the attending physician about the residents' foot conditions. Certified Nursing Assistants (CNAs) also failed to report and document their observations of the residents' feet. The podiatrist did not provide appropriate medical foot care and treatment, as evidenced by the condition of the residents' feet during observations and interviews. Resident 15, an elderly male with multiple diagnoses including Type 2 Diabetes Mellitus with Polyneuropathy and Hemiplegia, had severely neglected feet. Observations revealed foot drop, wounds, redness, swelling, dry and scaly skin, and fungal infections. Despite these conditions, the resident's feet had not been properly cleaned or assessed for months. The podiatrist's last visit did not result in adequate treatment, and the resident's care plan did not address his foot issues. Weekly assessments by LVNs were found to be incomplete and often copied and pasted without proper evaluation. Resident 36 also suffered from neglected foot care. The resident had thickened, discolored toenails and dry, flaky skin, causing discomfort. Despite a physician's order for podiatry care, the resident had not received any treatment since the last documented visit several months prior. The facility's policies on grooming and showering were not followed, as changes in the residents' skin and nails were not reported to the attending physician or documented in their care plans.
Failure to Complete Activity Assessments
Penalty
Summary
The facility failed to ensure activity assessments were completed for 16 of 16 sampled residents. During interviews and record reviews, it was found that none of the residents had their activity assessments completed within the required seven days of admission. The Activity Director (AD) confirmed that the assessments were not done for residents admitted on various dates, ranging from February to March 2024. The AD acknowledged that the purpose of the activity assessment is to determine the best activities for each resident to improve their mental health, and this was not achieved due to the lack of timely assessments. The facility's policy and procedure, dated 2021, mandates that an activity assessment should be completed within seven days of a resident's admission to develop an individualized care plan. However, the review revealed that this policy was not followed for any of the sampled residents. The AD admitted that the assessments were not completed as required, which could potentially impact the residents' physical, mental, and psychosocial well-being. The failure to conduct these assessments as per the facility's policy was a significant oversight in the care provided to the residents.
Failure to Ensure Staff Competencies
Penalty
Summary
The facility failed to ensure staff competencies for five sampled Licensed Nursing Staff, including three RNs and two LVNs. During interviews, it was revealed that a Certified Wound Nurse did not receive on-the-job training and had to figure out the computerized medical record system independently. The Director of Nursing admitted that while there used to be a competency checklist, it was currently unavailable as it was being updated, and no competency assessments were being conducted. The Director of Staff Development confirmed that there were no skills competency assessments documented for any of the licensed nurses. Additionally, the Administrator-in-Training stated that no performance evaluations had been conducted for the current nursing staff. A review of the facility's Policy and Procedure on On-the-Job Training indicated that training programs should be conducted to assist employees in performing their tasks, starting from the first day of employment and continuing until the department director is satisfied with the employee's performance. However, the lack of documented competency assessments and performance evaluations for the nursing staff indicates a failure to adhere to this policy, potentially resulting in harm to residents.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, properly store and label food, ensure employees followed the dress code policy, and serve food in a sanitary manner. During an observation, a dirty ladder and scaffolding with paint supplies were found in the kitchen, and the Maintenance Supervisor admitted to not removing them after completing ceiling repairs. Additionally, food items in the freezers and dry storage were found unsealed and without proper labeling, which was confirmed by the Certified Dietary Manager. The facility's policy required all food items to be labeled and dated, but this was not followed. Two staff members, including the Dietary Supervisor and a cook, were observed with uncovered facial hair, contrary to the facility's dress code policy. Furthermore, the Dietary Supervisor was seen returning a plated portion of turkey breast to the tray serving line, which was acknowledged as inappropriate by both the supervisor and the Registered Dietitian. These actions and inactions had the potential to spread foodborne illnesses throughout the facility, affecting all 71 sampled residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices for four sampled residents, leading to potential transmission of infectious diseases. For instance, a treatment nurse did not wear a gown while attending to a resident with MRSA, and another nurse did not perform hand hygiene before applying a clean dressing to a resident with bowel movement smears. Additionally, a resident with an ostomy had bowel movement leakage while eating, which was not addressed promptly, violating the facility's hygiene policy. Staff also failed to implement proper infection control practices for handling trash, transmission-based precautions, and laundry services. A CNA and a housekeeper were observed not performing hand hygiene after disposing of trash, and a laundry aide did not perform hand hygiene after sorting soiled linens. The infection preventionist admitted that the isolation cart was not fully stocked with necessary PPE, and there was no hand sanitizer available outside a resident's room. The facility did not conduct effective infection prevention surveillance activities. The infection preventionist admitted to not having records of hand hygiene monitoring and relied solely on visual observation. There were no indicators for surveillance, no data collection, and no analysis of surveillance activities. Additionally, the infection control committee meetings were conducted casually without proper documentation, and the infection preventionist could not provide meeting minutes.
Failure to Maintain Accurate Vaccination Records
Penalty
Summary
The facility failed to ensure that the Infection Control Preventionist (IP) maintained accurate records of Influenza and Pneumonia vaccinations for all current residents. During an interview and record review, it was found that 11 out of 71 current residents were not included in the immunization report, and the IP could not provide influenza vaccination records for these residents. Additionally, the IP was unable to verify the receipt or refusal of pneumonia vaccinations for 40 out of 71 residents. The IP confirmed that the facility census was 71, but only 60 residents were listed on the Immunization Report. Furthermore, only seven residents had signed declination statements for either the influenza or pneumonia vaccine, leaving a significant number of residents without documented consent or refusal for these vaccinations. The facility was unable to provide a policy and procedure related to influenza and pneumonia vaccinations when requested. According to the Centers for Disease Control (CDC) Guidelines, healthcare providers should incorporate immunization needs assessments into every clinical encounter, recommend needed vaccines, and maintain up-to-date records. The facility's failure to adhere to these guidelines and maintain proper vaccination records had the potential to compromise the health and well-being of the residents by not ensuring their immunity against certain infectious diseases.
Failure to Maintain Accurate Employee COVID-19 Vaccination Records
Penalty
Summary
The facility failed to ensure the Infection Preventionist (IP) maintained an accurate record of employee COVID-19 vaccinations for 110 of 159 employees. During an interview and record review, it was revealed that the IP did not have a log of the employee COVID-19 vaccinations, either manually or electronically. The IP kept a binder with some employee vaccination cards but acknowledged that not all employees had provided proof of vaccination. The IP admitted to requesting the vaccination cards verbally but did not follow up to ensure compliance. At the time of the review, only 49 employee vaccination cards were on file out of 159 active employees. The facility's policy and procedure titled 'Infection Prevention and Control Program' indicated that the IP was responsible for monitoring the health status of all employees and ensuring they received necessary health screenings and vaccinations. However, the IP's failure to maintain accurate records and follow up on missing vaccination cards resulted in an incomplete employee COVID-19 vaccination record. This deficiency was identified during a concurrent interview and record review with the IP, highlighting a significant gap in the facility's infection prevention and control measures.
Failure to Train Staff on Behavioral Health Requirements
Penalty
Summary
The facility failed to ensure that five licensed nurses were trained to meet the behavioral health requirements of 29 sampled residents. During interviews and record reviews, it was revealed that no competency assessments were being conducted for any staff, and there was no documentation of training specific to psychological or mental disorders. The Director of Nursing confirmed the lack of competency assessments, and the Director of Staff Development confirmed the absence of behavioral health training for the nursing staff. The Administrator provided a Diagnosis Report indicating that the facility had residents with various psychiatric diagnoses, including anxiety disorder, major depressive disorder, schizophrenia, and psychosis. The Facility Assessment Tool indicated that the facility was equipped to manage psychiatric and mood disorders, but it also highlighted the necessity for staff training and competencies in caring for residents with mental and psychosocial disorders. Despite this, the facility had not provided the required training, leaving the staff unprepared to address the behavioral health needs of the residents. This deficiency had the potential to result in staff being unable to provide appropriate assessments and interventions for residents with behavioral health needs.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to ensure that three of five sampled residents had their Minimum Data Set (MDS) assessments completed in a timely manner. Resident 43's Quarterly MDS assessment, dated 12/31/23, was completed on 3/20/24 but had not been transmitted. Resident 52's Quarterly MDS assessment, dated 12/29/23, was also not sent and was late. Resident 3's Annual MDS assessment, dated 1/24/24, was still in progress and had not been submitted. These delays were confirmed during interviews and record reviews with the MDS Coordinator. The facility's policy and procedures, dated 11/19, require comprehensive assessments of residents' needs to be conducted at intervals designated by OBRA and PPS requirements. Specifically, quarterly assessments must be conducted not less frequently than three months following the most recent OBRA assessment, and annual assessments must be conducted not less than once every twelve months. The failure to adhere to these timelines had the potential to result in unidentified health problems for the residents involved.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant conducted Medication Regimen Reviews (MRR) for two residents on psychotropic medications and did not perform monthly medication reviews for all 71 residents in the facility. For Resident 15, the Medication Administration Record (MAR) indicated the use of Abilify, Oxcarbazepine, and Depakote for bipolar disorder and Seasonal Anxiety Disorder, but there was no record of MRR conducted for the last three months. Similarly, for Resident 55, the MAR indicated the use of Quetiapine Fumarate, Donazepil, Memantine, and Lorazepam for psychosis and unspecified dementia, but there was no record of MRR for the last three months. The Minimum Data Set Coordinator (MDSC) confirmed the absence of these reviews during interviews and record reviews. Additionally, the Director of Nursing (DON) confirmed that the Pharmacy Consultant had not reviewed the medication regimens for a significant number of residents over several months. The facility's Census Report and Medication Regimen Review Report indicated that a large number of residents' medication regimens were not reviewed by the pharmacist on multiple dates. The facility's policy and procedure stated that the consultant pharmacist should review each resident's medication regimen at least monthly, but this was not adhered to, as confirmed by the DON and the facility's records.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that two residents, Resident 15 and Resident 26, had access to a call light, which had the potential for unmet care needs. During an observation and interview, Resident 26 was found sitting on her bed without a visible call light. She pointed to the bed's remote control attached to the side rail as her means to call for help. A CNA later retrieved the call light from the floor and attached it to Resident 26's side rail, acknowledging that it should have been within her reach. Similarly, Resident 15 was unable to find his call light, which was hanging on the wall behind his headboard. An LVN confirmed that the call light should have been within Resident 15's reach. The facility's policy indicated that all residents should have a call system they can operate, and the call light should be within reach of the resident.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to follow their policy and procedure titled Notification of Responsible Party when the responsible party was not notified of a change of condition for one of four sampled residents. Resident 17 had a skin tear on their toe, and the Change in Condition Evaluation indicated that the resident had self-notified. However, the Treatment Nurse confirmed that Resident 17 did not have the capacity to make their own decisions, and the responsible party was never notified about the change in condition. The resident's History and Physical Examination also indicated that Resident 17 did not have the capacity to understand and make health care decisions. The responsible party last heard from the facility several months prior. The facility's policy requires that the responsible party be notified of any significant change in the resident's condition, which was not followed in this case.
Failure to Obtain Proper Authorization for Resident Transfer
Penalty
Summary
The facility failed to provide accurate transfer/discharge documents signed by the responsible party for a resident with severe cognitive impairment. Resident 55, an elderly female with diagnoses including unspecified dementia, anxiety disorder, and adult failure to thrive, was admitted with a BIMS score indicating severe cognitive impairment. Despite this, the Social Services Director (SSD) allowed Resident 55 to sign transfer documents, even though the resident's mental status was not stable, and a physician had certified that Resident 55 did not have the capacity to understand and make healthcare decisions. The SSD acknowledged being aware of the resident's cognitive limitations but still proceeded with the transfer arrangements without the proper authorization from the responsible party. During interviews, Resident 55's family member (FM 1) confirmed that Resident 55 had never signed any healthcare documents and was not capable of doing so. FM 1 stated that they were the one who signed all paperwork for Resident 55 and were not notified about the transfer documents being signed by the resident. The facility's policy and procedure required notifying the responsible party of any changes involving the resident's health, which was not followed in this case. The SSD admitted to not knowing who signed the documents for Resident 55, leading to confusion and potential risk for the resident's transfer process.
Failure to Develop and Implement Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans for two residents, leading to potential negative outcomes. Resident 208 had multiple instances of refusing medical care, including hospital visits, blood sugar checks, medications, and dialysis. Despite these refusals and the complications they posed to his health, there was no specific care plan in place to address his noncompliance with care. The Director of Nursing (DON) acknowledged that there should have been specific care plans for Resident 208's issues, and the existing care plans were found to be vague and insufficient. Similarly, the facility failed to develop and implement a care plan for Resident 55 after a fall. The DON confirmed that there was no documented evidence of a care plan being created following the fall, which occurred on 3/12/24. The facility's policy and procedure for managing falls require that possible causes be identified within 24 hours and pertinent interventions be implemented to prevent subsequent falls. However, this protocol was not followed for Resident 55, indicating a lapse in the facility's adherence to its own policies.
Failure to Provide Preventive Measures and Weekly Wound Assessments
Penalty
Summary
The facility failed to provide preventive measures for pressure injuries for a resident diagnosed with quadriplegia, cellulitis of the buttocks, muscle wasting, and a history of Stage 2 pressure injury. Despite the resident's high risk for pressure ulcers, the facility did not provide a pressure-relieving mattress or appropriate padded dressings. The resident was observed with multiple pressure injuries, and staff acknowledged the lack of necessary preventive measures, such as a pressure-relieving mattress and protective devices for heels and ankles. The resident reported extended periods in a wheelchair and inadequate repositioning, contributing to skin breakdown. Additionally, the facility failed to ensure weekly wound assessments for two residents. For one resident, the last documented wound assessment was on 2/29/24, with no further assessments on 3/13/24, 3/20/24, and 3/27/24, despite the presence of multiple pressure injuries. The treatment nurse admitted to not completing the required weekly wound assessments and documentation. Another resident had a wound that started on 11/4/23 and reopened on 1/29/24, with no assessments documented between these dates to monitor the wound's progress. The facility's policies and procedures required weekly wound assessments and documentation, which were not followed. The Director of Nursing confirmed that weekly assessments should have been conducted for all wounds. The lack of adherence to these protocols resulted in the inability to monitor the healing progress of current wounds and potentially contributed to the development of additional pressure injuries.
Failure to Assess Bed Entrapment Risk for Residents
Penalty
Summary
The facility failed to ensure that five sampled residents were assessed for the risk of bed entrapment before the application of bedrails. During an observation and interview, it was found that the beds of these residents had quarter siderails up on each side, but no specific log or record of bed rail measurements was maintained. The Maintenance Supervisor acknowledged awareness of bed entrapment requirements but admitted that these had not been implemented at the facility yet. The Minimum Data Set Coordinator confirmed that the facility had not started assessing residents for bed entrapment risks, despite a recent discussion on the topic, and was unable to provide documentation for any of the five residents' bed entrapment risk assessments. The facility's policy and procedure on bed rails, dated 11/1/17, indicated that a Bed Rail Entrapment Risk Assessment should be completed by a licensed nurse before installing a bed rail. This includes assessing the resident for risk of entrapment and ensuring the bed's dimensions are appropriate for the resident's size and weight. However, the facility did not follow this policy, as evidenced by the lack of completed assessments and documentation for the five residents in question.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was scheduled and on duty for eight hours a day, seven days a week. This deficiency was identified during an interview and record review with the Director of Nursing (DON) on 3/28/24 at 10:26 a.m. The review of the nursing staffing schedule for October, November, and December 2023 revealed multiple dates where no RN was on duty for the required eight hours. Specifically, the dates in question were 10/1/23, 10/2/23, 10/7/23, 10/8/23, 10/13/23, 10/14/23, 10/19/23, 10/20/23, 10/25/23, 10/26/23, 10/31/23, 11/1/23, 11/6/23, 11/12/23, 11/18/23, 11/19/23, 11/24/23, 11/25/23, 11/30/23, 12/1/23, 12/6/23, 12/7/23, 12/12/23, 12/13/23, 12/18/23, 12/19/23, 12/24/23, 12/25/23, 12/30/23, and 12/31/23. The facility's policy and procedure, dated 2006, required an adequate number of nursing personnel to meet resident needs, including having at least one RN in the facility at all times for facilities licensed for 60 to 99 beds, in addition to the DON.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that two residents, Resident 135 and Resident 44, were free from a medication error rate greater than five percent. Specifically, two medication errors occurred within 29 opportunities, resulting in a 6.9% error rate. During an observation, RN 1 did not administer Resident 135's Eliquis, a blood-thinning medication, because it was not available in the medication cart. Similarly, LVN 5 did not administer Resident 44's Trelegy Ellipta inhaler for COPD as it was also unavailable. Both nurses indicated they would contact the pharmacy to resolve the issue. A review of the Medication Administration Records (MAR) for both residents confirmed that the medications were not given as scheduled. The Director of Nursing (DON) stated that nurses are expected to call the pharmacy four or five days before running out of medication to prevent such occurrences. The facility's policy on medication administration allows for medications to be administered one hour before or after the scheduled time, but this protocol was not followed in these instances, leading to the observed deficiencies.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure the safe administration of medication for one resident when medications were found on the resident's bedside table. Specifically, an albuterol inhaler prescribed for the resident's Chronic Obstructive Pulmonary Disease (COPD) was observed on the bedside table during a survey. The resident's Order Summary Report indicated that the inhaler should be used every six hours for COPD management. However, the inhaler was not stored securely as required by the facility's policy and procedure for medication storage. During the observation, two Licensed Vocational Nurses (LVNs) acknowledged the presence of the inhaler on the bedside table. One LVN admitted that the inhaler should not have been left on the table, while the other LVN stated that they had forgotten the inhaler there accidentally. The facility's policy mandates that medications and biologicals be stored safely and securely, accessible only to authorized personnel. The failure to adhere to this policy was evident in this incident, posing a risk of incorrect and unsafe medication administration.
Failure to Assess and Update Resident Food Preferences
Penalty
Summary
The facility failed to ensure dietary staff conducted an assessment of food preferences for Resident 56. During an interview, Resident 56 expressed dissatisfaction with the food served and stated that no one had discussed his food preferences with him. A review of Resident 56's dietary food card revealed that it had not been updated since his admission, despite the facility's policy requiring food preferences to be obtained as soon as possible and updated as needed. The Dietary Supervisor admitted responsibility for asking residents about their food likes and dislikes but had not seen Resident 56 since his admission. The Certified Dietary Manager confirmed that Resident 56's food preferences needed updating.
Failure to Serve Prescribed Pureed Diet
Penalty
Summary
The facility failed to ensure a pureed diet was served according to the physician's order for one resident. Resident 8, a [AGE] year-old female with a diagnosis of cerebral infarction, hemiplegia, hemiparesis, and dysphagia, was observed being fed a mechanical soft diet instead of the prescribed pureed diet with nectar thick liquids. This discrepancy was noted during an observation and interview with a Certified Nursing Assistant (CNA) and a Certified Dietary Manager (CDM), who admitted to giving the wrong diet to the resident. The facility's policy indicated that diet orders prescribed by the physician should be provided by the Food & Nutrition Services Department, which was not followed in this instance.
Failure to Provide Language-Assistance Service
Penalty
Summary
The facility failed to provide a language-assistance service for a resident who spoke a language native to the Punjab region of Pakistan. During an observation, the resident was seen trying to communicate with certified nursing assistants (CNAs) using body language and gestures, but they could not clearly understand each other. The CNAs admitted to using Google Translate to communicate with the resident, as the facility did not have a formal translation service. This lack of effective communication led to frustration for both the resident and the staff, as they struggled to understand the resident's needs. The Administrator-in-Training (AIT) acknowledged that there were two non-English speaking residents in the facility and that the staff assigned to these residents were supposed to speak their languages. However, the AIT admitted that the facility did not have a translation service and relied on calling staff at home or contacting the Ombudsman for social services for translation needs. The facility's policy indicated that qualified interpreters should be used, but this was not being followed. This failure had the potential for unmet care needs for the resident.
Failure to Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that four sampled residents received a summary of the Baseline Care Plan (BCP) within 48 hours of admission. Resident 15, who was readmitted after a recent hospitalization with diagnoses including Type 2 Diabetes Mellitus with Polyneuropathy and Hemiplegia, did not receive a complete BCP as sections for social services and rehabilitation services were incomplete. Additionally, there was no signature from Resident 15 or their representative indicating receipt of the BCP. Similarly, Resident 19, admitted with diagnoses including Metabolic Encephalopathy, Sepsis, and Altered Mental Status, did not have a signed BCP from their representative, despite brief assessments and plans of care being entered by various services. Resident 56, admitted with diagnoses including Unspecified Dementia, Type 2 Diabetes Mellitus, and Mood Disorder, did not receive their BCP within 48 hours of admission, as it was completed three days later. Lastly, Resident 209's BCP was not completed at all, as confirmed by the Director of Nursing (DON). The facility's policy and procedure require that a baseline care plan be developed within 48 hours of admission to ensure immediate care needs are met, but this was not adhered to in these cases.
Failure to Administer Medication According to Physician's Order
Penalty
Summary
The facility failed to administer medication according to the physician's order for one of three sampled residents (Resident 209). During an interview and record review with the Director of Nursing (DON), it was confirmed that Percocet was administered to Resident 209 outside of the physician-ordered pain scale on five occasions. Specifically, Percocet was given for pain levels of 5 and 6, despite the order specifying it should only be administered for severe pain levels of 7-10. The facility's policy and procedure for administering medications, revised in April 2019, indicated that medications should be administered in accordance with prescriber orders, including any required time frames. The DON acknowledged that nurses should follow the order and contact the physician if adjustments need to be made.
Failure to Notify MD and Conduct IDT Meetings for Resident's Condition Changes
Penalty
Summary
The facility failed to notify a Medical Doctor (MD) of a significant change in a resident's condition and did not conduct an Interdisciplinary Team (IDT) meeting for the same resident. Resident 208 had an extremely high blood pressure reading of 240/110 despite being given two medications to control it. The resident refused to be sent out for higher-level care, and there was no documentation that the MD was notified of this critical condition. The Director of Nursing (DON) confirmed that the MD should have been informed due to the potential complications that could arise from such a high blood pressure reading. Additionally, the facility did not conduct IDT meetings for Resident 208's new wound issues on three separate occasions. The resident acquired a stage 4 pressure wound to the right thigh, skin abrasions to both middle fingers, and necrotic tissue on the right hand and left second toe. The Treatment Nurse (TN) confirmed that IDT meetings were not held for these wound issues, which should have been done to ensure all facility staff were aware of the resident's condition and the necessary care procedures. The facility's policy and procedure require prompt notification of the resident's MD and the coordination of care through IDT meetings for significant changes in a resident's condition, which was not followed in this case.
Failure to Complete Fall Risk Assessments
Penalty
Summary
The facility failed to complete a fall risk assessment for two of three sampled residents, Resident 209 and Resident 55. Resident 209 was admitted with diagnoses including lack of coordination, muscle wasting, reduced mobility, and need for assistance with personal care, but did not have a fall risk assessment completed on admission. The Director of Nursing (DON) confirmed this omission during a review of Resident 209's medical record. Additionally, Resident 55 experienced a fall on 3/12/24, but the last fall risk assessment for this resident was completed on 10/5/23. The DON confirmed that no quarterly fall risk assessment or post-fall risk assessment was conducted for Resident 55. The facility's policy and procedure on the assessment and management of resident falls stipulates that fall risk assessments should be completed on admission, quarterly, and after a fall, which was not adhered to in these cases.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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