Vineland Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in North Hollywood, California.
- Location
- 10830 Oxnard Street, North Hollywood, California 91606
- CMS Provider Number
- 555011
- Inspections on file
- 35
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 22
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.
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.
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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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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