Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vineland Post Acute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple neurologic diagnoses, and total dependence for ADLs was identified as a fall risk and had a physician order for a tab alarm, but the facility did not develop a care plan addressing the alarm’s use, monitoring, or related interventions. A CNA reported leaving the dependent, non-alert resident in a wheelchair with a family member while obtaining hygiene supplies, with the tab alarm device left on the bed and not attached to the resident, so no alarm sounded. When the CNA returned, the resident was found on the floor after sliding from the wheelchair and reporting elbow pain. IDT notes and staff interviews confirmed there was no tab alarm care plan, and staff cited lack of education and incorrect implementation of the alarm, despite facility policies requiring alarms to be used per the care plan and comprehensive care plans with measurable objectives and timeframes.
A resident with severe cognitive impairment, Parkinson’s disease, dementia, and total dependence for ADLs had a physician order for a tab alarm and was assessed as a fall risk, but no specific care plan was developed for the alarm. A CNA left the resident in a wheelchair to obtain hygiene supplies, leaving the tab alarm on the bed with the magnet still attached, so it did not sound when the resident moved. While the CNA and family member were out of the room, the resident slid from the wheelchair to the floor and sustained an acute fracture, and staff later acknowledged the alarm had not been correctly implemented and was not included in the care plan.
A resident with COPD, type 2 DM with neuropathy, and HTN had multiple scheduled oral medications, including daily bupropion, clopidogrel, docusate, Jardiance, losartan, and TID Lyrica. On the survey day, an LVN prepared the resident’s morning medications and noted the ordered docusate capsule was not available in the cart. The LVN administered the remaining scheduled morning medications more than two hours after their scheduled time and later stated that the medications were the resident’s 9 a.m. doses, acknowledging they were late. Review of the MAR showed docusate documented as given at the scheduled time even though the LVN reported it had not yet been received or administered. The DON confirmed that medications were not given within the facility’s 1-hour window, physician orders were not followed, and the MAR was signed before actual administration, contrary to facility policy.
A resident with severe cognitive impairment and epilepsy was not readmitted to the facility after a hospital stay, despite being ready for discharge and facility policy supporting the right to return. The decision to deny readmission was made by the Administrator and DON, even though the facility was equipped to care for the resident and there was no policy-based reason for refusal. The resident was eventually readmitted after several days, resulting in a violation of the resident's right to readmission.
Licensed nursing staff failed to rotate insulin injection sites for three residents receiving insulin for DM management. The MAR/LOA showed repeated injections in the same abdominal or arm areas despite orders to rotate sites, and RN and DON interviews confirmed staff did not consistently follow the rotation instructions in the insulin orders and facility policy.
Failure to provide and document ordered skin care treatments. A resident with DM2, PVD, and multiple skin conditions had care plans and physician orders for treatment of the urethral orifice penile shaft, bilateral arms and legs, and face. Review of the TAR and progress notes showed no documented evidence that several ordered treatments were completed on multiple shifts, and the RN Supervisor/TN and DON stated that if care was not documented, it was not provided.
Failure to provide and document ordered diabetic foot ulcer care. A resident with DM2, diabetic polyneuropathy, PVD, and bilateral foot drop had orders for daily treatment of a right toe diabetic ulcer and a left heel diabetic wound. Review of the TAR and progress notes showed no documented evidence that the ordered care was completed on multiple day shifts, and RN and DON interviews confirmed that if care was not documented, it was not considered done.
A resident used a personal heating blanket in her room without a physician order, another resident had a fall mat blocked by an oxygen concentrator and trash can, and a third resident kept and used artificial tears at the bedside without an order. RN and DON interviews confirmed the lack of orders or oversight for the heating blanket and bedside eye drops, and staff acknowledged the fall mat was obstructed by objects placed on top of it.
Medication errors occurred when an LPN failed to give PRN clonidine for a resident’s elevated SBP despite an active order, and when licensed staff repeatedly used the same SC insulin sites for several residents despite orders to rotate injection sites. RN 1 and the DON stated the PRN BP medication should have been given when the BP was high, and that repeated insulin site use was a medication error because the orders required site rotation.
Failure to Document Advance Directive Information for A Resident: A resident with dementia, adult failure to thrive, and heart disease had fluctuating decision-making capacity, and the record showed a representative was involved. However, the BCPS and AHCD acknowledgement did not document that advance directive information was provided to the representative. RN, DSS, and DON all confirmed the documentation was incomplete, and the DSS stated she did not provide the information because the representative could not formulate an AD for the resident.
A facility failed to set low air loss mattresses according to resident weight and MD orders for two residents at risk for or already experiencing pressure injuries. One resident had DM, HF, muscle weakness, and intact cognition; the other had malnutrition, moderate cognitive impairment, and a stage 2 pressure ulcer. Staff observed both mattresses set at a higher setting than indicated by the residents’ weights, and RN and DON interviews confirmed the settings were not aligned with the orders.
Inadequate catheter care and unlabeled urinal. A resident with a suprapubic catheter had multiple missed or undocumented catheter care entries in the TAR, and during an observed treatment an RN cleansed the site but did not clean the catheter tubing. The DON and IP stated tubing cleaning is part of catheter care. In a separate finding, another resident’s urinal was observed unlabeled, despite staff stating it should be labeled with identifying information and date to prevent cross-contamination and UTI.
A resident with a suprapubic catheter, diabetes, and a history of UTI did not have documented evidence of ordered catheter/urostomy site care on multiple day shifts. The resident stated staff did not clean the catheter site, and an RN and the DON both reviewed the TAR and confirmed that if care was not documented, it was not done. The facility P&P required indwelling catheter care to be provided and documented.
A resident with respiratory failure, severe sepsis, immunodeficiency, and continuous O2 therapy had nasal cannula tubing observed touching the floor. An LVN acknowledged the tubing should not touch the floor for infection control, but only coiled the extra tubing onto the O2 concentrator and did not replace it. RN and DON interviews stated the tubing was contaminated and should have been changed, and the facility policy required tubing to be changed when soiled or contaminated.
An LVN failed to administer an ordered folic acid supplement during a routine med pass and gave a cranberry supplement dose that did not match the physician order. The resident had anemia and other chronic conditions, and the DON and RN confirmed the missed dose and incorrect dose were medication errors because meds and supplements must be available and administered as ordered.
Medication administration observations found a 7.14% error rate, with two errors in 28 opportunities. One resident with anemia and malnutrition missed a scheduled folic acid dose when an LPN documented the medication as given even though it was not available or administered. Another resident with a g-tube and neurologic impairment did not receive a complete thiamine dose when an LPN discarded the prepared crushed medication during troubleshooting of a clogged tube.
Expired insulin pen left in medication cart. An open Lantus Solostar pen for a resident with DM, respiratory failure, severe sepsis, and impaired cognition was found stored at room temperature in a med cart with no documented open date or staff initials. The LVN stated the pen was expired and should have been discarded, and the DON stated expired insulin could be ineffective and should not have remained in the cart. Manufacturer labeling and facility policy both required opened insulin pens to be used or discarded within 28 days.
A resident with DM, immunodeficiency, and a surgical site infection had physician orders allowing the flu vaccine and a consent form showing verbal agreement, but the MAR had no documented evidence that the vaccine was administered. The IP stated the resident consented for the flu clinic, yet there was no record confirming whether the vaccine was given, and the DON stated the facility is responsible for maintaining residents’ vaccine status and administering vaccinations as needed.
Resident Bedrooms Did Not Meet Required Square Footage: Surveyors found that 18 of 20 multiple-occupancy resident rooms did not meet the required 80 sq ft per resident. Room measurements showed several 2-bed and 4-bed rooms provided less than the minimum space, while RN and DON acknowledged room-size issues affecting equipment and furniture placement. The Administrator stated a waiver request had been made for most rooms, and the facility policy required bedrooms to meet the minimum square footage standards.
A facility failed to maintain a sanitary environment, leading to an infection control deficiency. A shared bathroom used by a resident with a complex medical history was found with overflowing trash and unflushed waste. Staff interviews confirmed the need for immediate cleaning to prevent infection spread, but the facility's policy on routine bathroom cleaning was not followed.
The facility failed to maintain room temperatures between 71 and 81 degrees Fahrenheit, affecting seven residents. Observations showed temperatures ranging from 65.1 to 70.3 degrees Fahrenheit. Staff interviews and facility policy emphasized the importance of maintaining appropriate temperatures for resident comfort and safety.
A resident in an LTC facility was physically and verbally abused by another resident, resulting in multiple injuries. The incident occurred when one resident struck another, pushed a bedside table causing a fall, and yelled profanities. The altercation was witnessed by an LPN, who documented the event and noted the injuries sustained by the victim. The facility's policy classified the incident as abuse.
The facility failed to maintain a homelike environment, as observed in missing lamp covers in two residents' rooms, peeling paint in two shower rooms, and a torn floor mat in a resident's room. The Maintenance Supervisor and DON acknowledged these issues, which could affect residents' safety and comfort.
The facility failed to obtain physician's orders and informed consent for the use of bed rails and bed placement against the wall for three residents, potentially leading to entrapment. Observations revealed that residents had beds placed against walls with side rails up, without proper documentation. The facility's policies require informed consent and physician's orders for such restraints, which were not followed in these cases.
The facility failed to provide in-service training on physical restraints, risking inappropriate use. A resident with limited mobility was observed with side rails up, unable to adjust them, while another resident's bed was against the wall for wheelchair space. The facility's policy considers such setups as restraints, but no training was provided to staff.
The facility did not post the actual hours worked by nursing staff in a visible and prominent place daily. Observations and interviews revealed that the information was located inside the nursing station and next to the staff clock-in area, making it inaccessible to residents and visitors. The facility's policy required daily posting of staffing information, including the facility name, current date, total number, and actual hours worked by RNs, LPNs, CNAs, and the resident census.
A facility failed to reassess a resident's ability to self-administer medication upon re-admission and quarterly, as required by the care plan. The resident, with type two diabetes and a colostomy, was initially assessed as capable of self-administration, but no further assessments were conducted. Interviews with the MDSN and DON confirmed the oversight, highlighting the importance of timely reassessments to prevent medication errors. The facility's policy requires reassessment under certain conditions, which were not followed in this case.
A facility failed to maintain the privacy of a resident's medical records when an LVN left the EHR open and unattended on a medication cart. The resident, who had severe cognitive impairment, was at risk of having their confidential information accessed by unauthorized individuals. The LVN admitted the oversight, and the DON highlighted the importance of protecting resident information, as per the facility's policy.
The facility failed to develop comprehensive care plans for two residents regarding bed placement against the wall, posing a risk for entrapment. Both residents had significant medical conditions and required assistance, yet lacked care plans to guide staff on necessary interventions. This oversight could lead to inconsistent care delivery.
A resident with dementia and other health issues was discharged without a documented referral to a home health agency, as required by the facility's discharge planning policy. The Social Services Director did not document the referral process or ensure the resident's post-discharge care needs were met, relying on the board and care to handle the referral. This oversight was contrary to the facility's policy, which mandates documentation of all assessments and services provided.
A resident with an indwelling catheter had their urinary drainage bag improperly positioned flat on the floor, contrary to facility policy. This practice, observed by staff, posed a risk of contamination and infection. The resident, who required assistance with personal hygiene, had a history of UTIs and sepsis. Staff interviews confirmed the correct procedure was not followed, highlighting a deficiency in catheter care.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease, missing required monitoring on two occasions. The DON confirmed the oversight, which was against the facility's policy requiring documentation of the dialysis access site status after treatment.
A facility failed to monitor side effects of psychotropic medications and signs of bleeding for a resident with dementia and Parkinson's, and did not specify aspirin dosage for another resident with hemiplegia and a recent MI. The lack of documentation and dosage specification violated facility policies, potentially delaying care and risking incorrect medication administration.
A facility failed to implement Enhanced Barrier Precautions for a resident with a gastrostomy tube. LVN and CNA did not wear isolation gowns during medication administration and repositioning, contrary to facility policy. The oversight was acknowledged by staff, and the DON confirmed the lack of infection control.
The facility did not make state inspection results readily accessible to residents and their representatives, as required. Observations revealed that the results were stored in a closed cabinet at the nurse's station, requiring individuals to request access from staff. Interviews with an RN and the DON confirmed this practice, which contradicted the facility's policy of having the survey binder available in the main lobby.
The facility did not meet the required 80 square feet per resident in multiple resident bedrooms, affecting 18 out of 20 rooms. Despite this, observations showed residents had adequate space, and staff could provide care safely. The facility requested a waiver, asserting that the room size did not impact residents' health and safety.
Failure to Care Plan and Implement Ordered Tab Alarm Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan for the ordered use of a tab alarm for a resident at high risk for falls. The resident was originally admitted with metabolic encephalopathy, Parkinson’s disease, difficulty in walking, dementia, and Alzheimer’s disease. An MDS assessment showed the resident had severe cognitive impairment and was fully dependent on staff for toileting, dressing, and personal hygiene. A fall risk assessment identified the resident as being at risk for falls, and on 2/18/2026 the physician ordered the use of a tab alarm for this resident. However, there was no corresponding care plan created that outlined individualized interventions, measurable objectives, or timeframes for the use and monitoring of the tab alarm. On the date of the fall, a CNA reported that the resident was not alert, was fully dependent on staff, and required two-person assistance for transfers between bed and wheelchair. The CNA stated that the resident had a tab alarm intended to alert staff when the resident moved, and that the same alarm was used in both bed and wheelchair. The CNA described leaving the resident in a wheelchair with a family member present while the CNA left the room to obtain hygiene supplies. At that time, the tab alarm device was on the bed and not connected to the resident, and its magnet remained attached, so no alarm sounded. When the CNA returned, the resident was found on the floor, having slid from the wheelchair, and later reported left elbow pain. Interdisciplinary team notes documented that the resident slid off the wheelchair onto the floor after the CNA stepped out, and that the family member walked out of the room with the tab alarm off. Facility staff, including an LVN, acknowledged that they could not definitively identify who removed the alarm, and that there had been a failure in the system related to lack of staff education on tab alarm use, lack of family knowledge, and incorrect implementation of the alarm. Review of the comprehensive care plan confirmed there was no specific care plan for the tab alarm despite the physician’s order. Facility policies on resident alarms and comprehensive care plans required that alarms be used and monitored in accordance with the resident’s care plan and that each resident have a comprehensive care plan with measurable objectives and timeframes, but these requirements were not met for this resident.
Failure to Care Plan and Properly Implement Tab Alarm Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area was free from accident hazards and that adequate supervision and safety devices were properly care planned and implemented for a resident at high risk for falls. The resident was originally admitted with metabolic encephalopathy, Parkinson’s disease, difficulty in walking, dementia, and Alzheimer’s disease. An MDS assessment showed the resident had severe cognitive impairment and was fully dependent on staff for toileting, dressing, and personal hygiene. The physician ordered a tab alarm for the resident, and a fall risk assessment identified the resident as being at risk for falls. On the day of the incident, a CNA reported that the resident was not alert, was fully dependent on staff, and required two-person assistance for transfers between bed and wheelchair. The CNA stated that the resident had a tab alarm that should sound when the resident moves or when the magnet is displaced, and that the same alarm was used in both bed and wheelchair. The CNA explained that when a family member asked about providing personal hygiene care, the CNA left the room to obtain supplies, leaving the resident in a wheelchair and the tab alarm on the bed with the magnet still connected to the alarm unit. Because the alarm was not attached to the resident and the magnet remained in place, no alarm sounded when the resident moved. Interdisciplinary team notes documented that the resident slid off the wheelchair onto the floor while the CNA was out of the room and the family member had walked out of the room with the tab alarm off. When the CNA returned, the resident was found lying on the floor and reported left elbow pain; the resident was later transferred to a higher level of care and diagnosed with an acute fracture. Review of the comprehensive care plan showed there was no specific care plan for the use of the tab alarm, despite the physician’s order. Facility staff acknowledged that there was no care plan for the alarm and that this resulted in no defined interventions for nurses to follow, and that the tab alarm was not implemented correctly at the time of the fall, contrary to the facility’s policies on resident alarms and comprehensive care plans.
Late and Inaccurate Medication Administration for a Resident
Penalty
Summary
Surveyors identified a deficiency in medication administration for Resident 4 related to failure to follow physician orders, late administration of scheduled medications, and inaccurate documentation on the Medication Administration Record (MAR). Resident 4 was admitted with diagnoses including COPD, type 2 diabetes with neuropathy, and essential hypertension, and had intact cognition per the MDS. Physician orders included daily bupropion, clopidogrel, docusate sodium, Jardiance, losartan, and three-times-daily Lyrica for polyneuropathy. On the survey date, an LVN prepared Resident 4’s scheduled 9 a.m. medications outside the resident’s room and identified that the ordered docusate sodium 250 mg capsule was not available in the medication cart. At 11:33 a.m., the LVN administered the prepared medications (bupropion, clopidogrel, Jardiance, losartan, and Lyrica) to Resident 4, confirming these were the resident’s scheduled 9 a.m. medications. The LVN stated that Lyrica was ordered three times daily at 9 a.m., 1 p.m., and 5 p.m., and acknowledged that the 9 a.m. medications were administered late. The LVN also reported that Resident 4’s systolic blood pressure was elevated at 162. Record review of the MAR for the month showed that the docusate sodium 250 mg capsule was documented as given at 9 a.m. on the same day, despite the LVN stating that the medication had not been received and would be administered once the supply arrived. The LVN acknowledged that medications should be documented as given only after administration and that documenting prior to administration could mislead other nurses. The DON confirmed that facility policy required medications to be administered within one hour before or after the scheduled time and that the MAR only reflected scheduled times, not actual administration times. The DON stated that Resident 4’s medications were administered late, physician orders were not followed, and the MAR was signed before the docusate was actually administered, contrary to the facility’s medication administration policy.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident following a discharge to a General Acute Care Hospital (GACH), despite the resident being ready for discharge from the hospital and the facility's own policies supporting the right to readmission. The resident, who had diagnoses including epilepsy and muscle weakness and was assessed as severely impaired in thought process and requiring maximal assistance with activities of daily living, was admitted to the facility in September and discharged to the hospital in December. When the hospital determined the resident was ready for discharge, the facility's Social Service Worker, Administrator, and Director of Nursing all communicated that the resident would not be accepted back, even though the facility's policies required readmission after hospitalization and there was no indication that the resident was ineligible for return. Interviews with facility staff confirmed that the decision not to readmit the resident was made by the Administrator and DON, and that the facility was equipped to care for the resident. The facility's policies, reviewed with the DON, explicitly stated the right to readmission after hospitalization, regardless of payment source, and did not provide any justification for denying the resident's return. The resident was ultimately readmitted several days later, but the delay constituted a violation of the resident's right to readmission as outlined in facility policy.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
Licensed nursing staff failed to rotate subcutaneous insulin administration sites for three sampled residents who were receiving insulin for diabetes management. The deficiency was identified through interview and record review and involved repeated injections being given in the same area despite orders and facility policy directing site rotation. The facility’s policy for injections stated that repeated injections should be rotated, and the prescribing information for the insulin products also directed rotation of injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. Resident 2 was admitted and later readmitted with diagnoses including type 2 DM with hyperglycemia and diabetic chronic kidney disease. The resident’s order for Humulin R included instructions to rotate the administration site. The location-of-administration record showed multiple injections given in the abdomen-left upper quadrant on several dates. During interview, RN 1 stated there were multiple instances from 10/2025 to 12/2025 when staff did not rotate the insulin site, and the DON stated there was no excuse for staff not to rotate the site because the electronic record could be checked to see where the last dose was given. Resident 24 had diagnoses including type 2 DM, heart failure, and muscle weakness, and was assessed as having intact cognition and the ability to understand and make decisions. The resident’s insulin aspart order included a direction to rotate injection sites. The administration record showed repeated injections to the left arm and then repeated injections to the right arm over multiple dates, rather than consistent rotation. RN 1 stated staff did not rotate the site from 9/2025 to 12/2025, and the DON stated staff should have rotated the site to prevent lipodystrophy and that administering insulin on lipodystrophy sites affects absorption. Resident 4 was admitted with diagnoses including type 2 DM with hyperglycemia, severe sepsis, and immunodeficiency, and had impaired cognition with no capacity to understand and make decisions. The resident had orders for insulin glargine and insulin lispro, both with instructions to rotate administration sites. The administration record showed repeated use of the abdomen-left upper quadrant, abdomen-right lower quadrant, and abdomen-left lower quadrant across multiple insulin doses. RN 1 stated there were multiple instances from 11/2025 to 12/2025 when staff did not rotate the insulin site, and the DON stated staff should have rotated the site and that there was no excuse for not doing so.
Failure to Provide and Document Ordered Skin Care Treatments
Penalty
Summary
The facility failed to provide and document skin care treatments according to physician orders, the resident’s care plans, and the resident’s choices for one resident with diabetes mellitus type 2, diabetic polyneuropathy, peripheral vascular disease, and a history of male genital organ disease. The resident’s assessments indicated he could understand others and make himself understood, but he required substantial to maximal assistance with bathing and toileting hygiene and needed ointments/medications and nonsurgical dressings for skin conditions. The resident’s care plans addressed a skin infection secondary to impetiginization, pink erythematous scaly plaques to the bilateral upper extremities and facial area, and impaired skin integrity related to the urethral orifice penile shaft. Physician orders included cleansing and dressing the urethral orifice penile shaft with normal saline, zinc oxide ointment, dry dressing, and abdominal pad; applying ammonium lactate lotion to the bilateral arms and legs; applying fluocinonide cream to the bilateral arms and legs; cleansing open areas on the bilateral arms and applying xeroform dressing and band aid; applying ketoconazole cream to the face; and applying mupirocin ointment to the bilateral arms and legs. During observation, the resident was awake and lying in bed and stated that facility staff does not take care of him. Review of the TAR and progress notes showed no documented evidence that ordered treatments were completed on multiple shifts in December 2025, including missed documentation for the urethral orifice penile shaft, bilateral arms and legs, and face on several day and evening shifts. The RN Supervisor/Treatment Nurse stated she documented treatments after providing them, but could not remember whether some treatments were actually given on certain dates, and stated that if it was not documented then it was not done. The DON stated skin care treatments are to be provided and documented in the TAR, and that if the LN does not document care, then the care was not provided.
Failure to Provide and Document Ordered Diabetic Foot Ulcer Care
Penalty
Summary
The facility failed to ensure appropriate foot care was provided and documented for one resident with diabetes mellitus type 2, diabetic polyneuropathy, peripheral vascular disease, and bilateral foot drop. The resident’s record showed he was admitted in 2021 and most recently readmitted on 11/18/2025. The MDS indicated he could understand others and make himself understood, and he required substantial to maximal assistance with several activities of daily living, including bathing and toileting hygiene. His record also showed he had a right foot second toe diabetic ulcer and a left heel diabetic ulcer, with care plans in place for both wounds. Physician orders directed staff to cleanse the right foot second toe ulcer with normal saline, pat dry, paint with betadine, and leave open to air every day shift, and to cleanse the left heel diabetic wound with normal saline, pat dry, paint with povidone iodine solution, and leave open to dry once daily. Review of the 12/2025 TAR and progress notes showed no documented evidence that the ordered treatment was completed on multiple day shifts, including 12/4/2025, 12/7/2025, 12/8/2025, and 12/13/2025. During interview, RN 1 stated she worked some of those day shifts and could not remember whether the treatments were provided, and stated that if it was not documented then it was not done. The DON reviewed the records and stated that diabetic ulcer foot care is provided per physician orders and documented in the TAR to verify completion. The DON also stated that even if a resident refuses treatment, the refusal is documented in the TAR, and that if the LN does not document care, then the care was not provided. The DON stated the facility P&P was not followed when there was no documented evidence that diabetic foot care was provided to the resident.
Unsafe resident environment and unauthorized bedside medication use
Penalty
Summary
The facility failed to keep the environment free of accident hazards for three residents. Resident 31 was admitted with diagnoses including hypothyroidism, polyneuropathy, and localized edema. Her H&P indicated she had the capacity to understand and make decisions, while the MDS showed moderate cognitive impairment and dependence to partial assistance with mobility and ADLs. The OSR did not include an order allowing use of a personal heating blanket, yet during observation she was seen using her own heating blanket in her room. RN 1 confirmed the blanket came from home, and later stated there was no physician order for its use and no care plan addressing it. Resident 5 was admitted and readmitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction. Her H&P indicated she had the capacity to understand and make decisions, while the MDS showed severe cognitive impairment and total dependence for mobility and ADLs. The OSR did not include an order for a floor mat, and the resident was assessed as at risk for falls. During observation in her room, a floor mat was present at the right side of the bed with an oxygen concentrator and a trash can placed on top of it. LVN 2 stated there should be no oxygen concentrator or trash can on the mat because it defeats the purpose of the fall mat. Resident 22 was admitted with a diagnosis of mild protein-calorie malnutrition. Her H&P indicated fluctuating capacity to understand and make decisions, and the MDS showed moderate cognitive impairment and dependence with ADLs. During observation, a bottle of GeriCare Artificial Tears without a lid was on her overbed table, and the resident stated she kept and used her eye drops there for dry eyes. The physician orders for the month did not include artificial tears, and RN 1 stated there was no physician order for bedside self-administration. The DON stated medications kept at the bedside without a physician's order pose a risk for infection, medication errors, and adverse reactions.
Medication Errors Involving PRN Antihypertensive and Repeated Insulin Site Use
Penalty
Summary
The facility failed to ensure a resident with essential hypertension received PRN clonidine when the resident’s systolic blood pressure was elevated. Resident 19 had an order for clonidine 0.1 mg by mouth every 6 hours PRN for SBP greater than 160 or DBP greater than 100. During the medication pass, the resident’s blood pressure was measured at 171/63 mm Hg, but the nurse did not prepare or administer the PRN clonidine at that time. Record review and interviews showed the nurse did not recognize or act on the PRN blood pressure order during the medication pass. RN 1 stated the facility process required the licensed nurse to note the elevated blood pressure and administer the PRN medication per the order parameters, and stated Resident 19’s SBP was high during the routine medication pass. The nurse later stated he was not aware of the PRN order and did not check for it, and acknowledged he should have administered clonidine when the blood pressure was 171/63 mm Hg. The facility also failed to rotate subcutaneous insulin administration sites for multiple residents. Resident 2 had an order for Humulin R with instructions to rotate the administration site, but the location record showed repeated injections in the abdomen left upper quadrant. Resident 24 had orders for insulin aspart with instructions to rotate the injection site, but the location record showed repeated injections in the same arm areas over time. Resident 4 had orders for insulin glargine and insulin lispro with instructions to rotate administration sites, but the location record showed repeated injections in the same abdominal areas across multiple administrations. RN 1 and the DON stated the licensed staff should have rotated the insulin sites and identified the failure to do so as a medication error.
Failure to Document Advance Directive Information for Resident Representative
Penalty
Summary
The facility failed to ensure Resident 26’s medical record documented that advance directive information was discussed with the resident representative. Resident 26 was admitted on 4/10/2025 and readmitted on 11/5/2025 with diagnoses including adult failure to thrive, atherosclerotic heart disease of native coronary artery, and dementia. The resident’s H&P dated 11/7/2025 noted fluctuating capacity to understand and make decisions, and the MDS dated 4/16/2025 indicated the resident could make self-understood and understand others, with moderately impaired cognition. The MDS also indicated the resident and significant other participated in assessment and goal planning. The Baseline Care Plan and Summary dated 11/5/2025 indicated the resident had a representative, but it did not state whether advance healthcare directive formulation information was provided to that representative. The AHCD Acknowledgement Form dated 4/11/2025 showed the representative was contacted by phone to ask whether the resident had an advance directive, and it indicated the resident did not have one. However, the form did not document that advance directive formulation information was provided to the resident representative. During interviews and record review, RN 1 stated the AHCD was incomplete because it did not show whether advance directive formulation information was provided to the resident representative, and the BCPS also did not show this. The DSS stated she did not provide advance directive formulation information to the resident representative because the representative could not formulate an advance directive for the resident, and she left the AHCD response boxes blank. The DON also stated the AHCD and BCPS were incomplete because they did not indicate whether advance directive formulation information was provided to the resident representative.
Low Air Loss Mattress Settings Not Matched to Resident Weight and Orders
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury for two residents by not setting their low air loss mattresses according to each resident’s weight and physician’s order. Resident 24 had diagnoses including type 2 DM, HF, and muscle weakness, and was assessed as having intact cognition and requiring substantial assistance with mobility and ADLs. The resident had an order for a low air loss mattress for wound management with monitoring for setting accuracy and functionality every shift, and the care plan included checking for proper functioning and monitoring air pressure with the appropriate setting based on weight. During observation, Resident 24’s low air loss mattress was found set at number 4, while the attached sticker indicated number 2. Staff stated the resident’s latest weight was 114 lbs. and that the mattress should have been set at number 2. RN 1 reviewed the resident’s record and stated the order required the mattress to be set according to weight, and the DON stated staff should have set the mattress according to the resident’s weight and physician’s order. The DON also stated licensed staff should check the mattress setting during environmental rounds to ensure the therapeutic effect of the mattress was achieved. Resident 22 had diagnoses including mild protein-calorie malnutrition and a stage 2 pressure ulcer of the back, buttock, and hip. The resident was assessed as having moderate cognitive impairment, dependence to setup assistance with mobility and ADLs, and risk for pressure ulcer/injury. The resident had an order for a low air loss mattress for wound management with monitoring for setting accuracy and functionality every shift, and the care plan included use of the low air loss mattress as ordered. During observation, Resident 22’s mattress was set at number 4, while staff stated the resident’s latest weight was 128 lbs. and the bed should have been set at number 3. RN 1 and the DON both stated the mattress should have been set according to the resident’s weight and physician’s order.
Inadequate catheter care and unlabeled urinal
Penalty
Summary
Resident 25 had an indwelling suprapubic catheter and diagnoses including diabetes mellitus, UTI, obstructive and reflux uropathy, and urinary device-related conditions. The resident’s care plan directed staff to cleanse the suprapubic catheter ostomy site and provide catheter care as ordered. The physician’s treatment order dated 11/17/2025 directed daily cleansing of the suprapubic catheter ostomy site. A review of the TAR and progress notes for 12/2025 showed no documented evidence that suprapubic catheter care was completed on 12/4/2025, 12/7/2025, 12/8/2025, and 12/13/2025. RN 1 stated she worked some of those shifts but could not remember whether catheter site care was provided, and stated that if it was not documented then it was not done. The DON stated indwelling catheter care is provided per physician’s orders and documented in the TAR, and confirmed that when there is no documentation, the care was not provided. The DON also stated the facility P&P was not followed when there was no documented evidence that catheter care was provided to Resident 25. During an observation of catheter care, RN 1 cleansed the urostomy site and applied a new dressing but did not cleanse the catheter tubing. RN 1 stated she only cleans the tubing when it looks dirty and did not notice it was dirty. The IP stated indwelling catheter care always includes cleaning the catheter tubing. The DON confirmed that for Resident 25, the catheter tubing should be cleansed during catheter care and not only when it appears dirty. For Resident 36, the urinal bottle was observed hanging unlabeled. The IP, RN 1, and DON stated the urinal should be labeled with identifying information and date to prevent cross-contamination and UTI, but the urinal in the room did not have the required label.
Failure to Document and Provide Ordered Catheter Care
Penalty
Summary
The facility failed to ensure appropriate suprapubic catheter and urostomy site care was provided for Resident 25 in accordance with physician orders and facility policy. Resident 25 was admitted with diabetes mellitus, UTI, obstructive and reflux uropathy, and a suprapubic catheter, and the care plan identified the resident as having a suprapubic catheter related to urinary conditions and at risk for UTI. The resident’s order summary included an order to cleanse the suprapubic catheter ostomy site daily, and the care plan directed staff to provide catheter care as ordered. During observation and interview, Resident 25 stated facility staff did not take care of him and did not clean his urostomy catheter, and he reported having had UTIs in the past. Review of the 12/2025 TAR and progress notes showed no documented evidence that suprapubic catheter care was completed on multiple day shifts, including 12/4, 12/7, 12/8, and 12/13. RN 1 stated she provided daily catheter care on weekdays when working as the treatment nurse and that if care was not documented, it was not done. The DON reviewed the records and stated indwelling catheter care is to be provided per physician orders and documented in the TAR, and that if care is not documented, then it was not provided. The DON stated the facility P&P was not followed when there was no documented evidence that catheter care was provided to Resident 25. The facility P&P required residents with indwelling catheters to receive appropriate catheter care, with documentation of care provided in the medical record.
Oxygen Tubing Left on Floor and Not Replaced
Penalty
Summary
The facility failed to ensure respiratory care was provided in accordance with professional standards of practice for one sampled resident who was admitted with respiratory failure, severe sepsis, and immunodeficiency, and who lacked capacity to understand and make decisions. The resident’s MDS indicated continuous oxygen therapy, and the order summary directed oxygen via nasal cannula at 2 liters per minute with titration to maintain SPO2 at or above 92 percent. The care plan also included monitoring oxygen tubing during rounds and removing and discarding tubing that made contact with the floor. During a concurrent observation and interview, the resident’s oxygen tubing attached to the nasal cannula was observed touching the floor while the resident was in the room with an LVN. The LVN stated the tubing should not be touching the floor due to infection control and coiled the extra tubing that had touched the floor onto the oxygen concentrator, but did not change the tubing. RN and DON interviews later stated the tubing should have been replaced because it was contaminated and could cause respiratory infection. The facility policy required oxygen to be administered consistent with professional standards of practice and stated that oxygen tubing and mask/cannula should be changed weekly and as needed when soiled or contaminated.
Medication Administration Error: Missed Folic Acid and Wrong Cranberry Dose
Penalty
Summary
Pharmaceutical services were not provided in accordance with physician orders for one resident during a medication administration observation. The resident had diagnoses that included adult failure to thrive, severe protein-calorie malnutrition, anemia, osteoporosis, and essential hypertension. The resident’s assessment indicated she usually could understand others and make herself understood, and she required substantial to maximal assistance with toileting, bathing, lower body dressing, and mobility. During the 9 a.m. medication pass observation, an LVN prepared the resident’s medications and administered a cranberry dietary supplement from a bottle labeled 450 mg, even though the physician order was for cranberry 400 mg once daily. The LVN did not prepare or administer the ordered folic acid 400 mcg tablet. After the administration, the LVN reviewed the orders and stated he had given a 450 mg cranberry tablet instead of the ordered 400 mg dose and should have clarified the correct dosage before administering it. He also stated the folic acid was not given because it was not in the medication cart. In follow-up interviews, the LVN stated the folic acid had not been delivered and would be administered late because the 9 a.m. medications should be given before 10 a.m. RN 1 stated the facility process is to reorder medications and supplements at least three days before they run out, and that the nurse needs to ensure all medications are on hand for administration. RN 1 stated the missed folic acid dose was a medication error, and that administering a cranberry dose different from the physician’s order was also a medication error. The DON stated the facility process is to follow physician orders for the right dose and right time, and confirmed that folic acid was not available for administration and that the wrong cranberry dose was given.
Medication Error Rate Exceeded Limit
Penalty
Summary
The facility failed to keep its medication error rate below 5 percent during medication administration observations. Surveyors identified 2 medication errors out of 28 total opportunities, resulting in a 7.14% error rate and affecting 2 residents observed during medication pass. The deficient practices involved one resident who did not receive a scheduled folic acid dose and another resident whose thiamine dose was not fully administered during a g-tube medication pass. For one resident with diagnoses including adult failure to thrive, severe protein-calorie malnutrition, anemia, osteoporosis, and hypertension, the physician ordered folic acid 400 mcg by mouth daily for supplementation. During the 9 a.m. medication pass, an LVN prepared and administered the resident's medications but did not prepare or give the folic acid tablet. The LVN stated the medication had not yet been delivered and documented the medications as given. In interview, the LVN acknowledged the folic acid was not administered, and RN and DON interviews confirmed that the medication should have been available in the cart and that the omission was considered a medication error. For another resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, metabolic encephalopathy, and a feeding tube, the order was for thiamine HCl 100 mg via g-tube daily. During observation, an LVN crushed the tablet, mixed it with water, and attempted to administer it through the g-tube after flushing the tube. When the medication would not pass, the LVN set the mixture aside in a clean drinking cup while troubleshooting the clogged tube, then discarded the prepared medication after the tube was cleared and proceeded with the rest of the administration. The LVN stated the dose should not have been discarded and that the resident did not receive the correct dose. RN and DON interviews confirmed that discarding the prepared thiamine prevented the resident from receiving the complete ordered dose and constituted a medication error.
Expired insulin pen left in medication cart
Penalty
Summary
The facility failed to discard one opened, expired Lantus Solostar insulin pen for Resident 4 that was stored at room temperature in Medication Cart 2. During observation with an LVN, the open pen was found in the cart with a pharmacy label showing a start date and an expiration date, but there were no staff initials or documentation on the pen indicating when it had been opened. The LVN stated there was no open date on the pen and believed it had been opened when it arrived from the pharmacy, which would have made it expired. The LVN also stated the pen was expired and should have been discarded according to facility policy. Resident 4 was admitted with diagnoses including DM, respiratory failure, and severe sepsis. The resident’s H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS indicated the resident rarely to never could make self-understood and understand others and had impaired cognition. The MAR showed insulin glargine was administered multiple times during the month reviewed. The DON stated expired insulin could be ineffective and the dose could cause a reaction in the resident, and that the insulin should not have been in the medication cart and should have been discarded. The manufacturer’s labeling stated opened Lantus Solostar pens should be stored at room temperature up to 86 degrees Fahrenheit and used or discarded within 28 days of opening or once room temperature storage began, and the facility policy stated insulin pens should be disposed of after 28 days or according to the manufacturer’s recommendation.
Missing Flu Vaccine Documentation and Administration
Penalty
Summary
The facility failed to keep updated vaccination documentation and failed to administer the 2025/2026 influenza vaccine for one of five sampled residents, Resident 13. Resident 13 was admitted on 2/18/2025 with diagnoses that included DM, immunodeficiency, and infection at the surgical site following a procedure. The resident’s MDS dated 2/25/2025 indicated the resident could understand others and be understood, and required substantial to maximal staff assistance with toileting, bathing, dressing, personal and oral hygiene, and mobility. Resident 13’s physician orders dated 11/7/2025 included an order that the resident may have the flu vaccine, and an influenza vaccine consent form dated 10/1/2025 documented verbal consent to receive the vaccine. During interview and record review, the IP stated the resident consented to the flu vaccine and there was a flu vaccine clinic on 10/2/2025, but there was no documented evidence that the vaccine was administered. The MAR did not show administration, and the IP stated she was not sure whether Resident 13 had received the flu vaccine. The DON stated the facility is responsible for maintaining documentation regarding residents’ vaccine status and administering vaccinations as needed.
Resident Bedrooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that residents' bedrooms met the required 80 square feet per resident in multiple resident rooms. During the recertification survey, surveyors identified 18 of 20 rooms that did not meet the federal space requirement, including rooms with two beds measuring between 136.6 and 141.55 square feet total and rooms with four beds measuring between 272.43 and 281.89 square feet total, resulting in less than 80 square feet per resident in each of those rooms. The report stated that the deficient practice had the potential to result in inadequate space to provide safe nursing care, privacy for residents, and limit residents' ability to maneuver personal care devices. During observation, residents were seen in multiple resident bedrooms and were noted to have adequate space to move freely, with enough room for staff to provide care and for beds, side tables, dressers, and resident care equipment. RN 1 stated that most rooms did not meet the 80 square feet federal regulation per resident, but there was enough space for staff to provide care. The DON stated there were issues with room size affecting the placement of equipment and furniture in the rooms. The Administrator acknowledged that a request for a room waiver had been made for all rooms except certain listed rooms, and stated there was no clutter and residents were happy. The facility policy required resident bedrooms to be designed and equipped for adequate nursing care, comfort, and privacy, and to measure at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in single resident bedrooms.
Infection Control Deficiency Due to Unclean Shared Bathroom
Penalty
Summary
The facility failed to enforce its own policy related to maintaining a safe and sanitary environment, resulting in a deficiency in infection control. During an observation, a shared bathroom used by a resident was found with overflowing toilet paper in the trash and stool and urine in the toilet bowl. This situation was confirmed by interviews with the resident, a Certified Nurse Assistant (CNA), the Infection Preventionist (IP), and the Director of Nurses (DON). The CNA acknowledged the need for immediate cleaning and sanitization, while the IP and DON recognized the potential risk for infection spread due to the shared use of the bathroom by multiple residents. The resident involved had a complex medical history, including Parkinson's disease, metabolic encephalopathy, acute pancreatitis, urinary tract infection, dementia, hypertension, asthma, and Alzheimer's disease. The resident was severely cognitively impaired and required moderate assistance with activities of daily living. The facility's policy, titled 'Routine Bathroom Cleaning,' dated December 19, 2022, mandates maintaining a clean and sanitary environment to prevent cross-contamination and transmission of healthcare-associated infections. However, the policy was not adhered to, as evidenced by the unclean state of the shared bathroom.
Failure to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain room temperatures within the required range of 71 to 81 degrees Fahrenheit, affecting seven residents. Observations conducted on December 19, 2024, revealed that room temperatures ranged from 65.1 to 70.3 degrees Fahrenheit, all below the minimum required temperature. The Maintenance Director confirmed these readings during a series of observations conducted between 11:45 a.m. and 11:55 a.m. Interviews with facility staff, including the Maintenance Director, Administrator, and Director of Nursing, highlighted the importance of maintaining appropriate room temperatures for resident comfort and safety. The facility's policy, last reviewed on April 17, 2024, also emphasized the need to maintain comfortable and safe temperature levels in resident areas. Despite this, the facility did not adhere to its policy, resulting in room temperatures that could compromise resident comfort and safety.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident. On the morning of November 17, 2024, Resident 2 struck Resident 1, pushed a bedside table towards him, causing Resident 1 to fall to the floor, and yelled profanities at him. This incident resulted in Resident 1 sustaining multiple injuries, including abrasions on his left forearm, lower back, and left posterior leg, as well as bruises and discoloration on his right thigh. The altercation was witnessed by LVN 1, who responded to Resident 1's call for help and observed Resident 2 attempting to strike Resident 1 while yelling profanities. Resident 1 was admitted to the facility with diagnoses including metabolic encephalopathy, bipolar disorder, and muscle weakness. He required substantial assistance with daily activities such as toileting, showering, and dressing. On the day of the incident, Resident 1 was found on the floor by LVN 1, who noted his injuries and documented the event in the Change in Condition Evaluation and Progress Notes. Despite the physician's order to transfer Resident 1 to a hospital for further evaluation, he refused the transfer. Resident 2, who was admitted with diagnoses including encephalopathy and schizophrenia, was also involved in the incident. He admitted to being physically aggressive towards Resident 1 but could not provide a reason for his actions. The facility's policy on abuse, neglect, and exploitation was reviewed, indicating that the incident was considered a resident-to-resident altercation and classified as abuse. The Director of Nursing confirmed the incident as abuse based on the facility's policy, highlighting the failure to protect Resident 1 from harm.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for its residents, as evidenced by several deficiencies observed during a survey. In the case of two residents, their room was found to have overhead lamps with missing covers, which the Maintenance Supervisor acknowledged but was unaware of when they went missing. The Director of Nursing confirmed that the absence of lamp covers could result in inappropriate lighting, detracting from a homelike setting. This oversight indicates a lapse in maintaining the residents' right to a comfortable and safe environment. Additionally, the facility did not maintain the shower rooms adequately, as observed with peeling paint on the floors of two shower rooms. The Maintenance Supervisor noted that the peeling was likely due to the use of disinfectants, which could lead to potential mold growth. The Director of Nursing acknowledged the risk of mold exposure to residents and suggested that the issue might require professional intervention to address the peeling and potential mold. Furthermore, a resident's floor mat was found to be in poor condition, with a tear that could pose a tripping hazard. The MDS Coordinator identified the issue during an observation, and the Director of Nursing confirmed the need for immediate replacement to prevent accidents. These deficiencies collectively highlight the facility's failure to uphold its policy of providing a safe, clean, and homelike environment for its residents.
Failure to Obtain Consent and Orders for Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless needed for medical treatment, as evidenced by the lack of physician's orders and informed consent for the use of bed rails and the placement of beds against the wall for three residents. Resident 25 was observed with quarter rails on both sides of the head of the bed and the bed placed against the wall without a physician's order or informed consent. The Infection Preventionist confirmed the absence of these documents and acknowledged that the use of bed rails and the bed's placement could be considered restraints, potentially leading to entrapment. Similarly, Resident 21's bed was placed against the wall with quarter bed rails, also lacking a physician's order and informed consent. The Director of Nursing confirmed that informed consent should be obtained to discuss the risks and benefits of such arrangements, especially for residents who are not cognitively intact. The facility's policy indicated that physical restraints, including bed rails and bed placement against the wall, should only be used when medically necessary and with proper documentation. Resident 33, who lacked the capacity to make decisions, was found with the bed against the wall and side rails up, without informed consent or a physician's order. The Director of Nursing stated that informed consent should be obtained from the resident's family representative, given the resident's cognitive impairment. The facility's policies emphasized the need for informed consent and physician's orders for the use of physical restraints, highlighting the facility's responsibility to evaluate the appropriateness of such requests and inform residents or their representatives of the associated risks and benefits.
Deficiency in Restraint Use Training
Penalty
Summary
The facility failed to provide in-service training regarding the use of physical restraints, which placed residents at risk for inappropriate restraint use. This deficiency was identified during interviews and record reviews. The facility's policy on competency evaluation requires that each employee meets appropriate competencies and skills for their job, but the Director of Staff Development (DSD) could not locate any competencies or in-services related to physical restraints. Resident 33 was admitted with multiple diagnoses, including COPD and generalized muscle weakness, and was observed with bilateral side rails up on their bed, which they were unable to lower. The resident's Minimum Data Set (MDS) indicated they required assistance for mobility and had limited ability to understand and communicate. The MDS Nurse confirmed the resident's bed was positioned against the wall with side rails up, which the resident could not adjust. Resident 14, who had the capacity to understand and make decisions, was observed with their bed against the wall to allow space for wheelchair maneuvering. The resident confirmed the bed's position, and a Certified Nursing Assistant (CNA) corroborated this setup. The facility's policy on a restraint-free environment states that bed positioning against a wall can be considered a form of restraint, and the facility is responsible for evaluating the appropriateness of such arrangements. However, the lack of in-service training on restraints suggests a gap in staff competency regarding restraint use.
Failure to Post Nursing Staff Hours Visibly
Penalty
Summary
The facility failed to post the actual hours worked by licensed and unlicensed nursing staff responsible for resident care in a visible and prominent place daily. During a tour of the facility, it was observed that the staffing information was not posted in a visible area. Interviews with the Staff Developer (DSD) and the Director of Nursing (DON) revealed that the staffing information was located inside the nursing station and next to where the staff clock in, respectively. Both acknowledged that the information was not visible to residents and visitors. The facility's policy and procedure required the posting of staffing information, including the facility name, current date, total number, and actual hours worked by Registered Nurses, Licensed Practical Nurses, Certified Nurse Aides, and the resident census, on a daily basis.
Failure to Reassess Resident's Medication Self-Administration Ability
Penalty
Summary
The facility failed to reassess a resident's ability to self-administer medication upon re-admission and quarterly, as specified in the resident's care plan. The resident, who was originally admitted with diagnoses including type two diabetes mellitus with diabetic polyneuropathy and a colostomy, was found capable of self-administration in an assessment dated over a year prior. However, no subsequent assessments were conducted after the resident's re-admission, despite the care plan's requirement for reassessment at specified intervals and upon significant changes in condition. Interviews with the Minimum Data Set Nurse (MDSN) and the Director of Nursing (DON) confirmed the oversight, acknowledging the importance of timely reassessments to prevent potential medication errors. The facility's policy mandates reassessment by the interdisciplinary team under certain conditions, such as significant changes in the resident's status or medication errors, but these were not adhered to in this case. This lapse in following the care plan and facility policy had the potential to lead to medication errors during self-administration by the resident.
Failure to Maintain Privacy of Resident's Medical Records
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records when a Licensed Vocational Nurse (LVN) left the electronic health record (EHR) of a resident open, unattended, and out of sight. This incident involved a resident who was admitted with diagnoses including dementia and generalized muscle weakness, and who had severe cognitive impairment as indicated in their Minimum Data Set (MDS). The LVN left the computer on top of the medication cart with the resident's electronic chart open while stepping away to assist a resident's family member. During an interview, the LVN acknowledged the mistake, stating that he should have locked the screen to prevent unauthorized access to the resident's confidential information. The Director of Nursing (DON) emphasized the importance of safeguarding medical information to prevent unauthorized access. The facility's policy on safeguarding resident identifiable information, last reviewed in April 2024, clearly states that medical records should not be left in open areas where unauthorized persons could access them.
Failure to Develop Comprehensive Care Plans for Bed Placement
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which was identified during a review of the physical restraints care area. Resident 21, who was admitted with diagnoses including Parkinson's disease and generalized muscle weakness, did not have a care plan addressing the placement of their bed against the wall. Observations and interviews confirmed that the bed was placed in a manner that could pose a risk for entrapment, yet no care plan was in place to guide staff on interventions to mitigate this risk. Similarly, Resident 33, who was admitted with chronic obstructive pulmonary disease and generalized muscle weakness, also lacked a care plan for their bed placement against the wall. The resident required assistance with mobility and was unable to move the side rails down, which increased the potential for entrapment. Despite these risks, there was no care plan developed to address the bed's position and the use of side rails. The facility's policy and procedure on comprehensive care plans, which mandates the development of person-centered care plans with measurable objectives and timeframes, was not followed. This oversight had the potential to result in inconsistent implementation of care plans, leading to delays or lack of care and services for the residents involved.
Failure to Document Home Health Referral for Discharged Resident
Penalty
Summary
The facility failed to address the needs of a resident, identified as Resident 48, for a home health agency referral prior to discharge. The resident, who was admitted with diagnoses including dementia, Alzheimer's disease, type II diabetes mellitus, and repeated falls, required assistance with activities of daily living due to moderate cognitive impairment and functional limitations. Despite the discharge order indicating the need for home health services, the Social Services Director (SSD) did not document the referral process or ensure that the resident's needs for post-discharge care were met, relying instead on the board and care to make the referral. The facility's policy on discharge planning required the SSD to assist residents in choosing an appropriate post-acute care provider, including home health agencies, and to document all assessments and services provided. However, the SSD failed to document conversations with the resident's family regarding the home health referral, which was necessary to ensure continuity of care and prevent rehospitalization. The Director of Nursing emphasized the importance of documentation to prove that staff made the referral, highlighting a lapse in following the facility's policy and procedure for documentation in the medical record.
Improper Positioning of Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, the facility did not maintain proper positioning of the urinary drainage bag for a resident with an indwelling catheter. The resident's urinary drainage bag was observed lying flat on the floor, which is against the facility's policy and procedure for catheter care. This practice has the potential to expose the drainage bag to contaminants, increasing the risk of infection. The resident in question had been admitted with an indwelling urethral catheter, a history of urinary tract infections, and sepsis. Despite the resident's cognitive impairment, the Minimum Data Set indicated that the resident required assistance with personal hygiene and had an indwelling catheter appliance. Observations and interviews with facility staff, including a CNA and the DON, confirmed that the drainage bag should not be placed on the floor due to the risk of contamination. The facility's policy emphasized the importance of positioning the catheter bag below the bladder level and away from the floor to prevent infection.
Failure to Document Post-Dialysis Assessment
Penalty
Summary
The facility failed to ensure proper post-dialysis assessment and documentation for a resident receiving hemodialysis. Resident 18, who was dependent on renal dialysis due to end-stage renal disease, was not assessed after dialysis treatment on two occasions, specifically on 10/18/2024 and 10/21/2024 during the 11 p.m. to 7 a.m. shift. The Director of Nursing confirmed that the licensed nurse did not document the required dialysis access site monitoring during these shifts, which should have been done every shift as per the physician's orders. This lack of documentation could potentially lead to missed complications at the dialysis access site. The facility's policy and procedure for hemodialysis, last reviewed on 4/17/2024, required nurses to monitor and document the status of the resident's access site upon return from dialysis treatment to check for bleeding or other complications. Additionally, the facility's documentation policy mandated that all assessments, observations, and services provided be recorded in the resident's medical record. The failure to adhere to these policies resulted in the deficiency noted during the survey.
Failure in Monitoring and Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for Resident 21 by not monitoring side effects related to the use of psychotropic medications and signs of bleeding on a specified date. Resident 21, who was admitted with diagnoses including Parkinson's disease, dementia, and a fracture, was prescribed quetiapine fumarate for dementia-related behaviors and aspirin for stroke prophylaxis. Despite orders to monitor for side effects and behaviors every shift, documentation was missing, indicating that the monitoring may not have been performed. This lack of documentation was confirmed during an interview with RN 2, who acknowledged the importance of monitoring to prevent missed behaviors or adverse effects. Additionally, the facility failed to specify the dosage of aspirin for Resident 15, who was admitted with conditions such as hemiplegia and a recent myocardial infarction. The physician's order for aspirin administration via gastrostomy tube did not include the dosage, which was observed during medication preparation and administration by LVN 1. The DON confirmed that the omission of the dosage was a violation of medication rights, which include ensuring the correct medication, route, dose, patient, and time. The facility's policies and procedures, last reviewed in April 2024, require documentation of all assessments and services provided, as well as ongoing evaluation of psychotropic medication effects. The failure to adhere to these policies resulted in potential delays in care and the risk of administering incorrect medication doses, as highlighted by the deficiencies observed in the care of Residents 21 and 15.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN 2 and CNA 1 during the care of Resident 19. Resident 19, who was admitted with a gastrostomy tube and other medical conditions, required Enhanced Barrier Precautions (EBP) to prevent the spread of infections. Despite clear signage and care plan instructions, LVN 2 did not wear an isolation gown while administering medications through the gastrostomy tube, and both LVN 2 and CNA 1 failed to don isolation gowns while repositioning the resident in bed. These actions were contrary to the facility's policy, which mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices. Interviews with LVN 2 and CNA 1 revealed an acknowledgment of the oversight, as both staff members admitted they should have worn isolation gowns to prevent potential cross-contamination and infection. The Director of Nursing confirmed that the failure to wear gowns during these activities exposed the resident to microorganisms and demonstrated a lack of infection control. The facility's policy on Enhanced Barrier Precautions, last reviewed in April 2024, specifies the necessity of personal protective equipment during high-contact activities, underscoring the deficiency in adhering to established infection control protocols.
Deficiency in Accessibility of State Inspection Results
Penalty
Summary
The facility failed to uphold residents' rights to access the results of state inspections by not posting these results in a prominent and accessible location. During observations conducted over several days, it was noted that the state inspection results were not visible in easily accessible areas within the facility. Instead, a notice on the consumer information board directed individuals to request the survey results from the nurse's station, where they were kept inside closed cabinets. This setup required residents and their representatives to ask staff members to view the results, which is contrary to the requirement for the results to be readily accessible without needing to make a request. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that the inspection results were stored in the nursing station, an area not accessible to residents and visitors. Both staff members acknowledged that while the results could be requested at any time, they were not displayed in a manner that allowed for easy access. The facility's policy and procedure indicated that the survey binder should be located in the main lobby for review by interested parties, highlighting a discrepancy between the policy and the actual practice observed during the survey.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that residents' bedrooms met the required space of 80 square feet per resident in multiple resident bedrooms. This deficiency was observed in 18 out of 20 rooms, where the square footage per resident was only 74.25 square feet in rooms with two beds and 75 square feet in rooms with four beds. Despite the deficiency, observations indicated that residents had adequate space to move freely, and nursing staff had sufficient room to provide care safely. During a Resident Council meeting, several residents expressed that they did not experience any issues with the space in their rooms, and the facility staff were able to provide care safely. The facility's Client Accommodations Analysis and a document titled RE: Requirement 483.70(d)(3) confirmed the insufficient square footage per resident. The facility had requested an ongoing waiver for rooms with less than the required square footage, asserting that the room size did not adversely affect residents' health and safety or impede their ability to attain their highest practicable well-being. The Director of Nursing also stated that there was enough space to provide care for the residents. The facility's policy indicated that resident bedrooms should measure at least 80 square feet per resident in multiple resident bedrooms, and the facility should request variances if the room sizes are in accordance with residents' special needs and do not adversely affect their health and safety.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Hollywood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Vista Nursing And Transitional Care Llc | 0.2 mi | ★★★★★ | 22 | 0 |
| Providence St Elizabeth Care Center | 1.2 mi | ★★★★★ | 33 | 2 |
| Four Seasons Healthcare & Wellness Center, Lp | 1.9 mi | ★★★★★ | 21 | 0 |
| All Saints Healthcare Subacute | 2.3 mi | ★★★★★ | 36 | 1 |
| Sherman Village Hcc | 2.7 mi | ★★★★★ | 14 | 0 |
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