Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Whittier Pacific Care Center during CMS and state inspections, most recent first.
The facility failed to develop complete, person-centered care plans for residents with feeding tubes and rehab needs. One resident with a GJ tube and another with a G-tube had enteral feeding orders, but their care plans did not include the ordered formulas and related tube-feeding details. A third resident’s care plan still listed RNA ambulation even though active orders did not include RNA services, and it did not include PT services despite a PT eval showing the resident needed therapy for strength and gait training.
A resident with hemiplegia, hemiparesis, aphasia, and ESRD on dialysis had documented ROM limitations in the upper and lower extremities, including severe ankle contractures. The resident was not given a JMS for the UEs after readmission, and restorative nursing ROM services were not provided to both arms for a period after readmission or to both legs during the reviewed period, despite PT/OT discharge recommendations and care plan interventions. Staff interviews and record review confirmed the gaps in assessment and RNA delivery.
Improper food storage, hand hygiene, and hair restraint during meal prep: expired and undated meat products were found in the freezer, a DA handled dirty equipment and then clean containers without changing gloves or washing hands, and a DS was observed with her hair net not fully covering her hair while preparing food. Facility policy required food items to be dated and labeled, hands to be washed and gloves changed between tasks, and hair nets to completely cover all hair.
Incomplete and inaccurate documentation affected multiple residents. An LVN charted two supplements as given even though they were not administered, an OT-related vomiting episode was not documented in the medical record, a psychotropic consent form for a resident on paroxetine did not include the dose or frequency, and an LVN failed to initial/document multiple scheduled meds in the MAR after administration. The DON stated the missing or incorrect charting could lead to miscommunication and duplicate dosing.
Staff failed to follow infection control practices for two residents on EBP and for a resident’s hearing aid. Two CNAs fed residents who required gloves and gowns for high-contact care but did not wear isolation gowns, despite signage and care plans directing EBP use. In another event, an LVN picked up a hearing aid that had fallen on the floor and placed it back into a resident’s ear without cleaning it first, even though the IPN stated resident-care items that fall on the floor should be disinfected.
Overflowing Exterior Trash Bin and Debris Left Nearby: An outside trash bin was observed overflowing with trash bags, with the lid unable to fully close, and two empty boxes were left on the ground nearby. The MS stated the lid should have been fully closed and boxes should not have been left out, noting the area had wildlife and greenery and that rodents could be attracted to overfilled bins or debris.
A resident with dementia, reduced mobility, and a history of CVA had full ROM in both knees on PT assessment, but later showed moderate loss of ROM in the left knee with resistance to stretching and only 90 degrees of flexion. Staff observed the resident’s legs bent and rotated, and nursing and rehab staff confirmed the decline was significant and not normal. The ADON stated the change should have been reported to the physician and interdisciplinary team, but the record had no documentation of notification, and the RP said the facility did not inform them of the change.
A resident with anxiety, dementia, and ventilator dependence had a discontinued PRN Lorazepam order renewed by an RN without MD/NP authorization. The new order did not require documentation of NPIs, and nursing staff administered the medication multiple times without documenting nonpharmacological interventions. The DON and NP stated the RN should have contacted the prescriber to renew the 14-day psychotropic order so the resident’s condition and the medication’s effectiveness could be evaluated.
Failure to Document Weekly Assessment of Post-Surgical Wound: A resident with a post-surgical incision after a hip replacement had ordered wound care, but the TXN did not complete or document the weekly wound assessment. The DON confirmed there was no weekly documentation of the wound’s size, color, or drainage after the initial skin assessment, and stated staff only assessed non-pressure wounds on admission or with a change in condition.
A resident with severe cognitive impairment, chronic respiratory failure, and a feeding tube was readmitted after the hospital converted the PEG to a GJ tube. The readmission assessment and GI documentation did not identify the GJ tube, and staff observed the tube with a Lopez valve connected to the J port. An LVN stated the J port was being used for both feedings and meds, while the G port was not being accessed, despite the order and standard practice for GJ tube use.
A resident with respiratory failure, hypoxia, and dementia did not receive oxygen at the ordered 2 L/min via NC when surveyors observed the NC off the resident’s nostrils and the concentrator turned off. The ADON confirmed the resident was not getting oxygen as ordered, then reapplied the NC and turned the concentrator on; staff interviews showed CNA and LVN were unaware of when or why the oxygen had been removed or turned off.
Failure to Reorder Resident Medications Before Supply Ran Out: A resident with HTN and osteoporosis had routine orders for Olmesartan Medoxomil, Isosorbide Dinitrate, and Raloxifene HCl, but an LVN found the bubble packs empty and could not administer the meds because they had not been refilled. The ADON stated refills should be requested before the supply reaches three days remaining, and the DON confirmed the pharmacy had no record of a refill request before the meds ran out.
Medication Error Rate Exceeded Threshold During Medication Pass: During a med pass, an LVN failed to check a resident’s pulse before preparing Metoprolol Succinate despite hold parameters, and three other ordered meds were unavailable because they had not been refilled. The resident had HTN, osteoarthritis, and osteoporosis-related treatment orders, and the DON confirmed there was no pharmacy record of refill requests for the missing meds before they ran out.
An opened vial of Aplisol was found stored in a medication refrigerator past the manufacturer’s 30-day discard date. The ADON stated it should have been discarded after opening and that use after 30 days would not be effective, while the DON stated expired Aplisol could cause a false negative TB test result. A facility P&P on injectable vials allowed use until the manufacturer’s expiration date or six months after opening unless otherwise specified.
A resident with contractures, muscle weakness, and impaired decision-making capacity had physician orders and care plans directing that a low air loss mattress (LALM) be set according to current weight for wound management and pressure ulcer prevention. The resident weighed 88 lbs, but during surveyor observation the LALM was found set at 120 lbs, despite nursing staff and the DON acknowledging it should be set lower than the resident’s weight (around 80 lbs) to allow proper pressure redistribution. The resident subsequently experienced a change in skin condition with reopening of fragile scar tissue and development of an in-house acquired Stage 1 pressure injury on the right trochanter, even though facility policy and the LALM manual required adjustment of the support surface based on the patient’s weight and care plan.
A resident with bilateral nephrostomy tubes, anoxic brain damage, and a persistent vegetative state experienced multiple episodes of nephrostomy tube malfunction and dislodgement associated with UTIs, each requiring hospital evaluation and tube exchange. The existing care plan only addressed securing the tubing with anchors and was not revised with new, individualized interventions despite repeated dislodgements, hospitalizations, and documentation of empty drainage bags, displaced tubing, and saturated dressings. Nursing staff and the DON acknowledged that the care plan was not updated and that no IDT meeting or root cause analysis was conducted to determine why the nephrostomy tubes continued to become dislodged, contrary to facility policy requiring ongoing assessment and care plan revision when outcomes are not met and after hospital readmissions.
Inaccurate Daily Staffing Postings: The facility failed to post daily direct care staffing information in a visible, prominent location and failed to ensure the postings reflected actual staffing rather than projected hours. Observation showed the postings were difficult for wheelchair users to see, and record review found mismatches between the posted RN, LVN, and CNA hours and the staffing sign-in sheets. DSD 1 stated the postings were based on projected data and had not been updated with actual staffing, and the DON stated the postings should accurately reflect actual staffing numbers.
A resident with severe cognitive impairment and a Foley catheter was observed with an uncovered urinary drainage bag, exposing its contents. Facility staff, including an LVN, DSD, and DON, confirmed that the bag should have been covered to maintain dignity, as required by facility policy. This failure violated the resident's right to be treated with dignity and respect.
The facility posted inaccurate CNA staffing information for the overnight shift, listing more CNAs and hours than were actually present according to sign-in sheets. Both the DSD and DON confirmed the discrepancy, acknowledging that the posted data did not match actual staffing records and could mislead residents and visitors.
The facility failed to keep two outdoor refuse containers closed with tight-fitting lids, as observed during an interview with the Dietary Supervisor. The containers were open, full, and overflowing, with one propped open by a red stick. The Maintenance Supervisor explained that staff used the stick to keep the lid open due to the height of the containers, but forgot to remove it. The facility's policy requires containers to be covered when not in use.
The facility failed to provide consistent restorative nursing care for four residents, leading to missed RNA services and exercises as ordered by physicians. Observations and interviews revealed that residents were often without necessary supports, and documentation confirmed missed sessions. Staffing shortages and transcription errors contributed to the deficiencies.
The facility failed to provide sufficient staffing for Restorative Nursing Assistant (RNA) services, leading to residents with limited range of motion not receiving prescribed exercises. RNA staff were often reassigned to Certified Nursing Assistant (CNA) duties due to staffing shortages, resulting in missed RNA sessions. Interviews with staff confirmed the issue, and the facility's staffing policy was not adhered to, causing a deficiency in care.
A facility failed to maintain a medication error rate below five percent when an LVN did not flush a G-Tube between administering medications to a resident, resulting in a 33.3% error rate. The resident, with a history of metabolic encephalopathy and sepsis, was dependent on staff for daily activities. The LVN admitted the error, and the ADON confirmed the correct procedure, highlighting the importance of flushing to prevent medication errors.
The facility's QAA committee failed to effectively identify and monitor a deficiency related to insufficient RNA staffing, affecting 19 residents who required RNA services to prevent mobility decline. The Administrator and DON were unaware of ongoing issues, such as RNAs being reassigned to CNA tasks and incorrect transcription of physician orders in the EMR system. This lack of oversight and ineffective QAPI processes contributed to the deficiency not being addressed.
The facility failed to adhere to infection control policies, resulting in deficiencies involving five residents. A resident's catheter bag and another's feeding tubing were found on the floor, posing contamination risks. A CNA did not perform hand hygiene between resident care, and family members of a resident did not follow Enhanced Barrier Precautions, increasing the risk of infection spread.
The facility failed to offer and provide information on Advance Directives to two residents during their admission and re-admission. One resident, with conditions including ventilator dependence and epilepsy, had no advance directive noted in their POLST form. Another resident, with muscular dystrophy and quadriplegia, had no signed Advance Healthcare Directive Acknowledgement form, despite discussions with Social Services. The absence of these directives was confirmed by facility staff.
A facility failed to transmit a resident's Discharge MDS to CMS within the required 30-day period. The resident, who had multiple diagnoses including metabolic encephalopathy and heart failure, was discharged to an Assisted Living Facility. The MDS Nurse admitted to forgetting to complete the discharge MDS, and the DON highlighted the importance of timely submissions for accurate reporting.
A facility failed to follow professional standards for G-Tube medication administration for a resident by not checking gastric residuals and not flushing the tube with water between medications. The resident, with severe cognitive impairment and multiple diagnoses, was at risk due to these oversights. The facility's policy requires flushing with water and checking residuals to prevent complications.
A resident at high risk for falls, with conditions including spinal stenosis and lack of coordination, fell over a wet floor sign while attempting to use the restroom unassisted. Despite requiring partial assistance for daily activities and having a history of falls, the facility did not initiate a bowel and bladder training program. Staff confirmed the oversight, acknowledging the need for such a program to prevent unassisted attempts to use the restroom.
A resident with a high risk for falls fell over a Wet Floor sign placed in front of their room, highlighting inadequate supervision and safety measures. The resident, with a history of falls and unsteady gait, was not monitored at the time of the incident, and the placement of the sign created a hazard. The facility's policy on maintaining a safe environment was not followed.
A resident with an indwelling Foley catheter for wound care management was not provided appropriate care, as the catheter was not properly secured and had sediment in the urine, indicating a possible UTI. The facility failed to document urine characteristics and did not report the sediment to a physician, contrary to its policies.
A facility failed to use appropriate alternative interventions before installing side rails for a resident with acute respiratory failure and hemiplegia. The resident's informed consent was incomplete, and there was no evidence of alternative measures being attempted. Staff interviews revealed a practice of automatically using side rails without documented alternatives, contrary to facility policy.
The facility failed to ensure that an LVN and a CNA completed their annual competency assessments, with lapses noted in 2024. The DON and DSD were unaware of the reasons for these omissions, despite facility policy requiring annual evaluations.
A facility failed to provide required specialized rehabilitation services for a resident by not conducting annual and quarterly joint mobility assessments. The resident, with conditions including hemiplegia and diabetes, had not received an OT joint mobility screening since 2022, and no PT or OT screenings were documented for 2024. The Director of Rehab acknowledged the oversight, and the DON highlighted the importance of these assessments in preventing contractures and maintaining independence.
A facility failed to explain an arbitration agreement to a resident's responsible party, who was unable to make an informed decision about the resident's care. The responsible party, who signed the document without understanding it, reported that the forms were handed over without explanation. The Admissions Coordinator stated the document was self-explanatory, while the Administrator acknowledged the need for proper explanation as per regulations.
A facility failed to maintain a functioning call light system for three residents, including one with Alzheimer's and another with hemiplegia. Despite pressing the call lights, the system did not signal at the nurse's station or outside the rooms. The issue was confirmed by the ADON and IPN, and the Maintenance Supervisor noted the malfunction had not been reported, despite daily checks.
The facility was found deficient in providing adequate room size, with 11 rooms measuring less than the required 80 square feet per resident. Despite this, residents and staff reported no adverse effects on care or mobility, as adjustments were made to accommodate space needs.
The facility failed to respond to call lights in a timely manner for four residents, leading to delays in assistance for personal hygiene and other needs. Residents reported waiting 1-2 hours for help, contrary to the facility's policy of responding within five minutes. This delay increased the risk of harm and discomfort for the residents.
A resident with acute respiratory failure and cerebral aneurysm was not properly offered the influenza vaccine, and the facility failed to provide necessary education or document the refusal with the required signature. The resident denied refusing the vaccine, contradicting the LVN's account. The facility's policy requires informed consent and documentation, which was not adhered to in this instance.
A resident with acute respiratory failure and cerebral aneurysm was not offered the Covid-19 vaccine, nor educated on its benefits and risks, contrary to facility policy. The resident's refusal was not properly documented, leading to a deficiency. Interviews revealed inconsistencies in the vaccine offer process, with the resident denying refusal and lack of informed consent.
A resident with severe cognitive impairment expressed discomfort with a male CNA providing pericare, but the facility failed to investigate or report the incident as required. The resident's preference for female CNAs was not reflected in staffing assignments, leading to the same male CNA being assigned again, causing the resident to feel unsafe. Communication breakdowns and non-adherence to abuse prevention policies were evident among facility staff.
A resident's rosary was lost due to the facility's failure to document it on the inventory list, despite being acknowledged by staff. The resident, with severe cognitive impairment, received the rosary from a priest, but it was not listed when the resident was transferred to another care unit. Interviews with staff revealed that the facility's policy required documentation of new items, but items from church services were not typically recorded, leading to the oversight.
A resident with severe cognitive impairment and anoxic brain damage did not receive a recommended dental x-ray due to a communication breakdown among staff. The dentist's recommendation was missed, and the facility's policy requiring social services to obtain needed services was not followed, potentially causing the resident to experience pain.
The facility failed to follow its infection prevention and control practices in handling dirty linens, affecting six residents. Isolation linens were not double-bagged or labeled, leading to potential cross-contamination. Interviews revealed discrepancies between staff practices and facility policies, increasing the risk of infection spread.
A resident with cognitive impairment fell from a shower chair, and the facility failed to notify the physician or responsible party. The ADON was unaware of the incident until two weeks later, and no documentation of required assessments or notifications was found, contrary to the facility's policy.
A facility failed to update care plans for two residents, one with a history of falls and another with behavioral issues. The first resident's fall was not documented, and their care plan was not revised to prevent future incidents. The second resident's disruptive behavior was not addressed in their care plan, leading to unawareness among staff about monitoring needs. These deficiencies highlight a lack of documentation and communication in care planning.
Two residents with pressure ulcers received inadequate care due to the use of rough, reusable washcloths instead of disposable wipes, as required by the facility's policy. The facility's insufficient supply of disposable wipes contributed to this issue, potentially hindering wound healing and causing discomfort.
A resident with a history of falls experienced a recurrent fall due to inadequate supervision and lack of intervention. The resident, diagnosed with muscle weakness, osteoarthritis, and dementia, fell after standing from a shower chair without shoes. The incident was not documented or investigated, and the facility's fall protocol was not followed, resulting in a deficiency in care and supervision.
The facility failed to provide adequate staffing for RNA services, leading to a resident not receiving prescribed exercises for two months. CNAs were assigned RNA duties without proper scheduling, affecting 19 residents. The facility lacked a clear list of residents in the RNA program, resulting in inconsistent care.
The facility did not update and post daily staffing information in a visible location, as required. On a specific day, the staffing information was outdated, showing data from several days prior. A last-minute change in RN staffing assignments led to the delay in updating the posting. The facility's policy mandates that direct care daily staffing numbers be posted for every shift, which was not followed, resulting in this deficiency.
Incomplete care plans for tube feeding and therapy services
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents with tube feeding and rehabilitation needs. For one resident with a GJ tube, chronic respiratory failure, and a tracheostomy, the record showed severe cognitive impairment, a feeding tube, and an order for Vital 1.5 enteral feeding at 32 cc per hour for 20 hours via pump. The comprehensive care plan did not include resident-specific goals or interventions for the GJ tube or the ordered formula feeding. Staff interviews confirmed that the care plan should have identified what would be used through the J-tube and G-tube, the plan, goals, interventions, and the formula so staff would know how to provide care. For another resident with respiratory failure, tracheostomy, and gastrostomy, the record showed severe cognitive impairment, a feeding tube, and an order for Glucerna 1.2 at 55 cc per hour for 20 hours via pump. The resident’s G-tube feeding care plan included goals to minimize weight loss and aspiration and interventions to administer enteral feedings as ordered, assess tolerance, and check the feeding bag, but it did not identify the ordered formula. Staff interviews stated the care plan should have included the G-tube formula, the size, medications through the tube, and the type of formula so staff would know what was ordered and monitor nutrition appropriately. For a third resident with difficulty walking, muscle weakness, hemiplegia, and hemiparesis following a cerebral infarction, the care plan for risk of further decline in contractures and tightness in both legs included RNA ambulation with a front wheeled walker three times per week or as tolerated and use of a right AFO in bed. The resident’s PT evaluation showed goals to improve strength for gait training and time out of bed, with maximum assistance needed for bed mobility and no gait or transfer testing due to refusal. The active physician orders did not include RNA services, and the MDS coordinator stated the care plan should have included PT services and that the RNA care should have been discontinued because the resident was not receiving RNA services.
Failure to Assess and Provide ROM Services
Penalty
Summary
The facility failed to assess and implement ROM interventions for one resident with significant mobility limitations after readmission. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, end stage renal disease with dialysis dependence, and aphasia following cerebral infarction. The resident’s record showed prior PT and OT discharge summaries recommending restorative nursing aide services, including ROM, AROM, PROM, and a resting hand splint for the right hand. The resident’s JMS records showed differing findings over time. An OT JMS documented full ROM in the left upper extremity and limited ROM in the right upper extremity, with recommendations for PROM to both arms. A PT JMS documented full ROM in both hips and knees but severe ROM loss in both ankles with plantarflexion contractures, and later another PT JMS again documented severe ankle ROM loss. The resident’s MDS also identified functional limitations in ROM in one arm and both legs. After readmission, the resident did not receive a JMS (OT) to assess upper extremity ROM within the timeframe described in the facility policy, and the DOR stated the resident’s baseline ROM in both arms was not assessed upon readmission because no JMS (OT) was completed. The record also showed gaps in restorative nursing services. The resident did not receive ROM exercises to both arms from readmission until the physician’s orders were entered for AAROM to the left arm and PROM to the right arm, and RNA documentation showed those arm exercises began only after that order. The resident did not receive ROM exercises to both legs during the period reviewed, despite PT discharge recommendations and care plan interventions for PROM to both legs. During observations, the resident used the left arm for eating and did not move the right arm, and later the right elbow was observed in extension with the right-hand joints bent into a loosely closed fist. Staff interviews confirmed the resident had not received RNA services for ROM to both arms and legs during the periods reviewed.
Improper Food Storage, Hand Hygiene, and Hair Restraint During Meal Preparation
Penalty
Summary
The facility failed to procure, store, prepare, and serve food under sanitary conditions when expired and improperly labeled meat products were found in the walk-in freezer. During observation, bags of turkey slices dated 9/2/2025, 9/26/2025, 10/28/2025, 12/9/2025, and 12/16/2025 were present, along with bags of ham slices dated 8/28/2025, 9/26/2025, and 1/1/2026, and a bag of pork patties with no open or used-by date. The facility’s Refrigerator & Freezer Storage Chart and policy required items to be properly dated, labeled, and discarded when expired or beyond the best-buy date, and staff stated the meat should not have remained in the freezer without a used-by date. During lunch preparation, a Dietary Aid was observed taking dirty equipment to the sink and then picking up clean metal containers without changing gloves or washing hands. The Registered Dietitian Nutritionist stated the Dietary Aid should have changed gloves after handling dirty dishes and before handling clean items for hygiene and infection prevention. The Dietary Aid and Dietary Supervisor both stated that gloves should be changed and hands washed before touching clean items to prevent cross contamination. The Dietary Supervisor was also observed with her hair net not properly covering all of her hair during kitchen activities. Her bangs were seen hanging out of the hair net on multiple observations, and at one point the hair net was halfway off her head while she moved around the kitchen during lunch preparation, including retrieving food and drinks from the refrigerator and using the mixer to mince and puree food items. The facility’s policy required a hair net or head covering to completely cover all hair at all times, and the RDN stated staff should not prepare food if the hair net is not properly placed.
Incomplete and inaccurate medication and clinical documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with its Charting and Documentation policy for four sampled residents. For one resident admitted with HTN, osteoarthritis of the left hip, and aftercare following joint replacement surgery, the MAR showed scheduled supplements including Oyster Shell and Glucosamine-Chondroitin. During a medication pass observation, an LVN prepared the resident’s 9 AM medications but did not administer those two supplements, yet later documented that they had been given. The LVN stated she documented the supplements by mistake and should have verified the MAR before charting them as administered. The DON stated the documentation error could prolong the next dose or supplement given and reduce therapeutic effectiveness. For another resident admitted after an unwitnessed fall with diagnoses including COPD, difficulty walking, muscle weakness, subarachnoid hemorrhage, subdural hemorrhage, and skull fracture, the record showed an OT session in which the resident became dizzy, sweaty, and then vomited while side-lying in bed. COTA 1 left the room to call the nurse, and RN 1 later assessed the resident’s blood pressure, oxygen saturation, and temperature. RN 1 stated the resident had one episode of vomiting on 3/11/2026, that the vomiting was verbally communicated to nursing staff on the next shift, and that it was not documented in the medical record. RN 1 stated the record had no evidence that the vomiting occurred. For a third resident admitted with depression and HTN, the physician ordered paroxetine 30 mg by mouth daily, and the MAR showed the medication was being given. During review of the psychotherapeutic drug informed consent form, the LVN who obtained the consent stated she did not document the dosage and frequency of paroxetine on the form. The DON stated the dosage and frequency should be documented on the consent form so the resident and responsible party are fully informed and can agree or disagree with the treatment. For a fourth resident with ALS and major depressive disorder, the MAR listed multiple medications scheduled for 9 AM, including apixaban, buspirone, docusate sodium, escitalopram, ferrous sulfate, folic acid, LiquaCel, metoprolol, multivitamin, omeprazole, Rilutek, and vitamin C. The LVN stated she administered those medications but did not document them in the MAR after giving them, and the DON stated that if the nurse did not document the medication administration, another nurse could think the resident had not received the medications and administer them again.
Infection Control Practices Not Followed for EBP Care and Hearing Aid Handling
Penalty
Summary
The facility failed to implement infection control practices for residents on Enhanced Barrier Precautions (EBP) and for a resident’s hearing aid that fell on the floor. Resident 79 had diagnoses including a history of sepsis, UTI, and muscle weakness, was severely cognitively impaired, and was dependent on staff for eating, bathing, toileting, and personal hygiene. Resident 79 was placed on EBP due to a sacrococcyx wound and a Foley catheter, and the care plan directed staff to post EBP signage and provide gloves, gowns, and mask. Resident 71 had diagnoses including quadriplegia, tracheostomy care, and a history of respiratory disease, had intact cognition, and was dependent on staff for eating, bathing, toileting, and personal hygiene. Resident 71 was also on EBP due to a tracheostomy site, with care plan interventions directing staff to post EBP signage and provide gloves, gowns, and mask. During observation, CNA 2 was feeding Resident 79 in the resident’s room while the EBP signage at the doorway indicated gloves and gown were required for high-contact care, including feeding, but CNA 2 was not wearing an isolation gown. CNA 2 stated she knew she was supposed to wear a gown for feeding because it was high-contact care, but she forgot. In a separate observation, CNA 3 was feeding Resident 71 while the doorway signage also indicated gloves and gown were required for high-contact care, but CNA 3 was not wearing an isolation gown. CNA 3 stated she forgot to wear the gown and added that the gown was to protect Resident 71 and other residents from infection. Resident 88 had diagnoses including cerebral infarction, muscle weakness, dysphagia, and dementia, and the MDS indicated clear speech, ability to express ideas and wants, understanding of verbal content, and severely impaired cognition. During an activity room observation, LVN 1 placed Resident 88’s hearing aid into the right ear, and the hearing aid fell out and landed on the floor while the LVN was attempting to place the left hearing aid. LVN 1 picked up the hearing aid from the floor and immediately placed it back into Resident 88’s right ear without cleaning it first. LVN 1 stated the hearing aid should have been cleaned after falling on the floor, and later stated it was not cleaned because she felt nervous. The IPN stated resident-care items that fall on the floor should be cleaned with disinfectant wipes and that a hearing aid should not be placed back into a resident’s ear after falling on the floor. The facility policy stated resident-care equipment, including reusable items, will be cleaned and disinfected.
Overflowing Exterior Trash Bin and Debris Left Nearby
Penalty
Summary
The facility failed to maintain a sanitary environment when the exterior trash storage area was observed with trash bags overflowing from an open bin, and the lid could not fully close. Two empty boxes were also observed on the ground near the bin during the survey observation. The condition of the trash area was documented as part of the deficiency related to maintaining a safe, sanitary, and comfortable environment for residents, staff, and the public. During interview, the Maintenance Supervisor stated the outside trash bin lid should have been completely closed and boxes should not have been left around the area. The Maintenance Supervisor also stated the surrounding area had a lot of wildlife and greenery, and that overfilled trash bins or empty boxes left out could allow rodents to come near the facility and potentially scare residents and family or carry disease that could transfer to residents. Facility policies reviewed stated that infectious and regulated waste shall be handled and disposed of in a safe and appropriate manner, and that infection control policies are intended to maintain a safe, sanitary, and comfortable environment.
Failure to Notify Physician and Responsible Party of Significant ROM Decline
Penalty
Summary
The facility failed to notify the resident’s physician and responsible party after a significant change in left knee range of motion was identified for one resident. The resident was admitted with diagnoses including encephalopathy, dysphagia, reduced mobility, muscle weakness, dementia, and a history of cerebral infarction without residual deficits. On the initial PT assessment, the resident had full range of motion in both knees, and the PT evaluation also documented normal range of motion in both legs. The resident was dependent for bed mobility and transfers, and PT later recommended a restorative nursing program with passive range of motion exercises to both legs. A later PT joint mobility screen showed moderate range of motion loss in the left knee, with resistance to stretching and only 90 degrees of flexion, and the DOR stated this represented a significant decline from the prior normal range of motion. During observation, the resident was seen lying in bed with both knees bent and both legs rotated to the right, with the left knee resting on top of the right knee and no positioning or cushioning device in place at the start of the session. RNA staff performed passive range of motion to both legs and were unable to extend the left knee past 90 degrees. CNA staff also observed the resident’s legs in a bent, rotated position and stated the resident had leg contractures and that the legs had been straight about one month earlier. Interviews with nursing and rehabilitation staff confirmed the decline in left knee range of motion and that it was not normal. The ADON stated the decline should have been reported to the physician and interdisciplinary team and that nursing should have been notified to contact the physician for another intervention. The ADON also reviewed the record and stated there was no documentation of the resident’s decline in left knee range of motion. The DON stated a change of condition assessment should be completed when a resident’s mobility declines to determine the reason for the change and to notify the physician and responsible party. The resident’s responsible party stated the facility did not notify them about the left knee range of motion limitation. The facility policy required prompt notification of the attending physician and resident representative when there was a significant change in condition.
Unapproved renewal of PRN Lorazepam and missing NPI documentation
Penalty
Summary
The facility failed to ensure one sampled resident was free of unnecessary psychotropic medication use when RN 4 renewed a discontinued PRN Lorazepam order without authorization from MD 1 or NP 1. Resident 4 was admitted with diagnoses including anxiety, dementia, and tracheostomy with ventilator dependence, and the MDS indicated the resident was rarely or never understood and had severely impaired cognition. The resident’s prior Lorazepam order had been limited to 14 days and included nonpharmacological interventions such as rest and repositioning, cues and reassurance, and redirection/diversion/reorientation. On 3/10/26, RN 4 entered a new telephone order for Lorazepam 1 mg via g-tube every 8 hours as needed for anxiety manifested by restless pulling of life-sustaining tubing, and the order stated informed consent was obtained by the responsible party from MD. The telephone order did not include instructions to provide or document nonpharmacological interventions before administration. The MAR showed Lorazepam was administered multiple times by nursing staff over the following days, and there was no documentation of nonpharmacological interventions before those doses. During interviews, LVN 8 stated he did not think NPIs needed to be documented because the order did not require it, while RN 2 stated the absence of NPI documentation could indicate they were not done. RN 4 later stated she forgot to include documentation of NPIs when she renewed the order and that she had put the new order in the chart without speaking to MD 1 or NP 1. RN 4 also stated she believed a refill being available at the pharmacy implied the provider wanted the medication renewed. The DON stated licensed nurses were expected to call the MD to renew PRN psychotropic orders and that RN 4 acted outside her scope by renewing the order without practitioner authorization. NP 1 stated he was not contacted to renew the medication and therefore did not have the opportunity to evaluate the resident’s condition, the medication’s effectiveness, or potential adverse effects.
Failure to Document Weekly Assessment of Post-Surgical Wound
Penalty
Summary
The facility failed to ensure weekly wound assessments were completed and documented for one resident with a post-surgical wound to the left lateral thigh after a left hip replacement. The resident was admitted with diagnoses including left hip replacement and hypertension, had intact cognition and memory on the MDS, and required surgical wound care. The physician ordered daily wound care to the incision site with cleansing using normal saline, pat dry, betadine, and a dry dressing. A skin assessment completed shortly after admission documented a surgical incision at the left lateral leg measuring 9 cm in length and 1 cm in width. During interview and record review, the TXN stated he did not assess or document the weekly wound assessment for the resident’s left lateral thigh surgical incision on 3/3/2026 and acknowledged responsibility for documenting wound location, type, size, drainage, tissue type, and surrounding skin. The DON stated weekly skin and wound assessment was important so staff could see whether the wound was getting better or worse and intervene timely, and also confirmed there was no weekly wound assessment showing the wound’s size, color, or drainage after the initial skin assessment. The DON further stated the facility policies did not specify a frequency for non-pressure ulcer wound assessments, and nurses only conducted and documented wound assessments for non-pressure ulcer wounds upon admission and when there was a change of condition.
Failure to Assess GJ Tube and Follow Tube Medication Orders
Penalty
Summary
The facility failed to ensure services were provided in accordance with professional standards of practice for enteral nutrition for one resident with a feeding tube. The resident was admitted and later readmitted to the facility with diagnoses that included a G-tube, chronic respiratory failure, and tracheostomy. The resident's MDS indicated severe cognitive impairment and that the resident had a feeding tube, and the H&P stated the resident did not have the capacity to understand and make decisions. On readmission from the acute care hospital, the progress note did not include an assessment of the resident's GJ tube. The clinical admission documented skin issue number eight as a G-tube site wound present on admission and skin issue number 35 as a G-tube site present on admission, but the gastrointestinal assessment did not identify that the resident had a GJ tube. The hospital discharge order stated the resident had been evaluated for nausea and vomiting and, due to high PEG residual, the resident's PEG was converted to a GJ tube. During observation and interview, the resident was seen with a GJ tube and a Lopez valve connected to the J port. The LVN stated the J port was for feeding and the G port was for medications, but the facility was only using the resident's port for both feedings and medications and was not accessing the G port. The facility's policies required a physical assessment including the gastrointestinal system, documentation of all relevant assessment data, and documentation of all services provided and enteral tube assessments and interventions.
Oxygen Therapy Not Maintained as Ordered
Penalty
Summary
The facility failed to ensure a resident with respiratory failure, hypoxia, and dementia received oxygen therapy at 2 L/min continuously as ordered by the physician. The resident’s record showed the oxygen order had been in place since 4/3/2025, and the Minimum Data Set indicated severely impaired cognitive skills and dependence on several activities of daily living. A weight and vitals summary showed oxygen saturation levels of 97-98 percent while oxygen was being administered via nasal cannula. During an observation on 3/9/2026 at 9:52 AM, the resident was lying in bed with the nasal cannula on the right side of the pillow and not applied to the nostrils, and the oxygen concentrator at the bedside was off. In a concurrent interview, the ADON stated the resident was not receiving oxygen as ordered, then inserted the nasal cannula, turned on the concentrator, and set it to 2 L/min; the resident’s oxygen saturation was then 94 percent. Staff interviews showed CNA 1 did not notice whether the cannula was in place or the concentrator was on during morning care, and LVN 2 stated she saw the oxygen in place and the concentrator on during rounding around 7:30 AM but did not know why, when, or who removed it and turned it off. The DON stated nurses should follow the physician’s oxygen order to ensure adequate oxygenation and resident safety.
Failure to Reorder Resident Medications Before Supply Ran Out
Penalty
Summary
The facility failed to provide pharmaceutical services for one resident by not reordering routine medications before the last doses were used, as required by the facility’s policy. Resident 112 was admitted with diagnoses including HTN, osteoarthritis of the left hip, and aftercare following joint replacement surgery, and the MDS dated 3/1/26 indicated the resident was cognitively intact. The resident’s physician orders included Olmesartan Medoxomil 20 mg daily for HTN, Isosorbide Dinitrate 5 mg daily for HTN, and Raloxifene HCl 60 mg daily for osteoporosis. During medication pass observation, an LVN set aside empty bubble packs for Olmesartan Medoxomil, Isosorbide Dinitrate, and Raloxifene HCl and stated the medications were not available and needed to be refilled by pharmacy. The ADON stated the facility’s protocol was to request refills at least one week before a medication ran out, and that nurses were expected to call the pharmacy when there was only a three-day supply left. The DON stated the pharmacy had no record of a refill request for these medications prior to 3/11/26 and confirmed the medications should have been refilled before they ran out.
Medication Error Rate Exceeded Threshold During Medication Pass
Penalty
Summary
The facility failed to maintain the medication error rate at less than five percent during a medication pass observation. Four medication errors were identified out of 30 opportunities, resulting in a 13.33% medication error rate and affecting one of three residents observed for medication administration. The errors involved Resident 112, who was cognitively intact and had diagnoses including HTN, osteoarthritis of the left hip, and aftercare following joint replacement surgery. During the medication pass, the LVN checked the resident’s blood pressure but did not check the pulse rate before preparing Metoprolol Succinate, even though the order required the medication to be held if the pulse was less than 60 bpm. The LVN stated she forgot to check the pulse because she was focused on the blood pressure. The LVN also set aside empty medication bubble packs for Olmesartan Medoxomil, Isosorbide Dinitrate, and Raloxifene HCl and stated she could not administer them because they were not available and needed to be refilled by pharmacy. The ADON stated the facility’s refill protocol was to request medication refills at least one week before a medication ran out, and that licensed nurses were expected to call the pharmacy when there was only a three-day supply left. The DON stated the pharmacy had no record of refill requests for the resident’s Olmesartan Medoxomil, Isosorbide Dinitrate, or Raloxifene HCl prior to the observation. The resident’s orders included Metoprolol Succinate for HTN with hold parameters for low SBP or pulse, Olmesartan Medoxomil for HTN, Isosorbide Dinitrate for HTN, and Raloxifene HCl for osteoporosis.
Expired Aplisol Vial Left in Medication Refrigerator
Penalty
Summary
The facility failed to ensure safe provision of pharmaceutical services in one of two medication storage areas by leaving an opened vial of Aplisol, a tuberculin purified protein derivative, in the medication refrigerator beyond the discard date required by the manufacturer. During an observation of Medication Storage Area 1, an opened Aplisol vial was found in the refrigerator, and the label stated that once entered, the vial should be discarded after 30 days. The vial had been opened and used on a prior date and remained stored in the refrigerator 11 days past the required 30-day discard date. During interviews, the ADON stated the vial should have been discarded 30 days after it was opened and that it would not have been effective if used after that time. The ADON also stated that using expired Aplisol could produce a false negative TB test result and that residents could unknowingly have TB without being treated. The DON stated it was important to store and discard medications and biologicals according to the manufacturer's guidelines so they could be used safely and effectively. A facility policy titled Vials and Ampules of Injectable Medications stated that medication in multi-dose vials may be used until the manufacturer's expiration date or six months after opening unless otherwise specified.
Improper Low Air Loss Mattress Setting Leads to Trochanter Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a low air loss mattress (LALM) was set according to a resident’s weight as ordered and care planned, resulting in an alteration in skin and reopening of fragile scar tissue on the right trochanter. The resident was initially admitted with diagnoses including sepsis, bilateral knee contractures, and muscle weakness, and a history and physical documented that the resident lacked capacity to understand and make decisions. Physician orders and active care plans for alteration in skin integrity and risk for pressure ulcers directed that the LALM be set according to the resident’s weight for wound management and pressure redistribution. Record review showed that the resident’s weight was 88 lbs, and the Treatment Administration Record for the month indicated that on one day shift the LALM was documented as set according to the resident’s weight. However, during observation in the resident’s room, surveyors found the LALM set at 120 lbs rather than at or below the resident’s current weight. Treatment nurses interviewed at the time of observation stated that the LALM setting should be based on the resident’s weight, that settings higher than the resident’s weight make the mattress firmer, and that for this resident a setting of 80 would have been appropriate, while 120 could be too firm. The DON similarly stated that the resident’s weight should always be higher than the LALM setting and that a higher setting could defeat pressure redistribution and potentially increase pressure on the skin. A change-of-condition assessment documented that the resident was noted with a change in skin condition during routine treatment, with the right trochanter area observed to be reopened at the site of previous fragile scar tissue, described as a small open area with minimal drainage and fragile surrounding skin. A subsequent skin issues document identified an in-house acquired Stage 1 pressure ulcer/injury on the rear right trochanter, with specific measurements and wound characteristics recorded. The facility’s policy on support surfaces directed staff to review the care plan and use redistributing support surfaces to prevent skin breakdown and provide pressure relief or reduction, and the LALM operator’s manual indicated that the mattress should be adjusted according to the patient’s weight or a health care professional’s suggestion. Despite these directives, the LALM was not maintained at a setting consistent with the resident’s weight and care plan interventions.
Failure to Revise Care Plan and Perform IDT Root Cause Analysis for Recurrent Nephrostomy Tube Dislodgement
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise a comprehensive, individualized care plan addressing recurrent nephrostomy tube dislodgement for a resident with bilateral nephrostomy tubes and complex medical conditions. The resident had diagnoses including anoxic brain damage, persistent vegetative state, artificial openings of the urinary tract (nephrostomy tubes), pyelonephritis, urinary calculi, and UTI. On admission and subsequent review, the care plan identified an alteration in urinary elimination and risk for UTI related to indwelling catheters (nephrostomy tubes), with an intervention to secure the left and right nephrostomy tubing with anchors each shift to minimize dislodgement. Despite this, the resident experienced multiple episodes of nephrostomy tube malfunction and dislodgement requiring hospital evaluation and tube exchanges. On one occasion, facility records and GACH documentation showed the resident was admitted with percutaneous nephrostomy malfunction and UTI, underwent right and left nephrostomy tube exchange, received antibiotics, and was then readmitted to the facility. Later, a Change of Condition note documented that the treatment nurse notified an RN that the resident’s right nephrostomy tube was dislodged, with hematuria noted in the left nephrostomy bag, and the resident was again sent to the hospital, where records indicated admission for UTI and dislodged right nephrostomy tube and a right nephrostomy tube exchange with IV antibiotics. Subsequent Change of Condition documentation described a CNA reporting that the left nephrostomy tube appeared out of place, the urine collection bag was empty, and the gauze dressing used to keep the tube in place was off and saturated with urine. The RN observed the nephrostomy tube inside the stoma but 13.5 cm out with urine leaking from the stoma, and the physician was notified with a request to transfer the resident for replacement. Further documentation showed another Change of Condition entry noting no urine output in the left nephrostomy bag and a new order from the physician to send the resident to the hospital for exchange. GACH records indicated the resident had multiple dislodged nephrostomies over the past few months, was paraplegic and bedbound, and had been seen at another hospital two to three days earlier for similar issues, with a subsequent left nephrostomy tube placement and antibiotics. Interviews with RN staff and the DON confirmed that, despite these recurring dislodgements, the care plan was not revised to include new or individualized interventions to prevent further nephrostomy tube dislodgement. RN 2 acknowledged that the care plan had not been updated with new interventions and stated it was important to keep the care plan updated. The DON stated that the IDT did not hold a meeting regarding the recurring nephrostomy tube dislodgements, that a root cause analysis was not done, and that it was never determined why the nephrostomy tubes continued to become dislodged, despite facility policy requiring ongoing assessment, IDT review, and care plan revision when desired outcomes are not met or after hospital readmissions. The facility’s written policy on comprehensive person-centered care plans stated that the IDT, in conjunction with the resident and representative, develops and implements a comprehensive care plan derived from thorough assessment, reflecting recognized standards of practice, and addressing underlying causes of problem areas. The policy further required that assessments be ongoing and care plans revised as residents’ conditions change, with IDT review and updates when there is a significant change in condition, when desired outcomes are not met, and when a resident is readmitted from a hospital stay. In this case, despite multiple nephrostomy tube dislodgements, repeated hospital admissions for nephrostomy malfunction and UTI, and documentation from hospital providers noting multiple dislodgements over months, the facility did not conduct an IDT meeting, did not perform a root cause analysis, and did not revise the resident’s care plan with individualized, preventative interventions specific to nephrostomy tube dislodgement.
Inaccurate Daily Staffing Postings
Penalty
Summary
The facility failed to ensure that daily direct care staffing information was posted accurately and in a visible, prominent location as required by its policy titled Posting Direct Care Daily Staffing Numbers. During observation, the staffing postings at both the Skilled Nursing and Subacute Nursing stations were not easily visible to residents who use wheelchairs, and the Skilled Nursing posting was placed approximately five feet above the ground. The postings also reflected projected staffing information rather than the actual staffing for each shift, including the 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM - 7:00 AM shifts. During interview and record review, the Daily Subacute Staffing Posting for 11/21/2025 showed staffing levels that did not match the Nursing Staffing Assignment and Sign-In Sheet, and DSD 1 stated the posting was based on projected data from the previous day's schedule and had not been updated with actual staffing data. The Daily SNF Staffing Posting also did not match the corresponding sign-in sheet, and DSD 1 stated the same issue applied there. DSD 1 further stated that staff members did not have access to update the posting and only DSD 1 was authorized to make changes. The P&P required staffing numbers to be posted within 2 hours of the beginning of each shift in a prominent location accessible to residents and visitors, and the DON stated the posting should accurately reflect actual staffing numbers rather than projected hours.
Uncovered Foley Catheter Bag Violates Resident Dignity
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, dementia, benign prostatic hyperplasia, and acute kidney failure was observed with an uncovered Foley catheter urinary drainage bag. The resident required significant assistance with daily activities and had a Foley catheter in place for urinary retention. During an observation, the urinary drainage bag was visibly exposed, showing yellow urine, and was not covered as required by facility policy. Interviews with facility staff, including an LVN, the Director of Staff Development, and the Director of Nursing, confirmed that the urinary drainage bag should have been covered to protect the resident's dignity, in accordance with facility policy and procedures. Review of the facility's policies further indicated that all residents are to be treated with dignity and respect, and that staff are expected to help residents keep urinary catheter bags covered. The failure to cover the urinary drainage bag constituted a violation of the resident's right to dignity and respect.
Inaccurate Posting of CNA Staffing Information
Penalty
Summary
The facility failed to ensure the accuracy of nurse staffing information posted daily, specifically regarding the number of certified nurse assistants (CNAs) working the 11 PM to 7 AM shift on several dates. The Daily Skilled Nursing Facility (SNF) Staffing Posting indicated that four CNAs worked these shifts, totaling 32 hours, while a review of the Nursing Staffing Assignment and Sign-In Sheets showed that only three CNAs actually worked, totaling 24 hours. This discrepancy was confirmed during interviews with both the Director of Staff Development (DSD) and the Director of Nurses (DON), who acknowledged that the posted information was inaccurate and did not reflect the actual staffing levels for those shifts. The facility's policy required accurate daily posting of nurse staffing data, including the number and type of nursing personnel providing direct care, to be displayed in a prominent location accessible to residents and visitors. The inaccurate postings had the potential to misinform residents and visitors about the actual number of CNAs available to provide care during the affected shifts. The DSD, who was responsible for completing the staff posting, and the DON both recognized that the posted information did not match the actual staffing records for the specified dates.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that two of four outdoor refuse containers were closed with tight-fitting lids and kept covered. During an observation and interview with the Dietary Supervisor, it was noted that the refuse containers were open, full, and overflowing with closed plastic bags of garbage hanging outside. One container had a red stick propping the lid open. The Dietary Supervisor acknowledged that the lids should be closed at all times. In a subsequent observation and interview with the Maintenance Supervisor, the red stick was removed, and the container was closed. The Maintenance Supervisor explained that the refuse containers' openings were too high for some staff, leading them to use the red stick to keep the lid open, but they forgot to remove it afterward. The facility's policy, dated October 2017, requires all garbage and refuse containers to have tight-fitting lids and be kept covered when not in continuous use.
Failure to Provide Consistent Restorative Nursing Care
Penalty
Summary
The facility failed to provide restorative nursing care, treatments, and services to minimize decline in joint range of motion (ROM) for four residents. These residents were ordered by their physicians to receive Restorative Nursing Assistant (RNA) assisted exercises and services. However, the facility did not ensure that these services were consistently provided as ordered. For instance, Resident 30 did not receive RNA services on multiple specified dates, and observations showed that the resident was often without the prescribed ankle-foot orthosis (AFO) and knee splints. The responsible party expressed concerns about the resident's condition deteriorating due to lack of proper care. Resident 70's physician order was inaccurately transcribed, leading to the resident receiving RNA services only three times a week instead of the ordered five times. Observations confirmed that the resident was not receiving the necessary exercises and AFO application as frequently as required. The RNA staff confirmed that the transcription error led to the resident not being scheduled for the correct number of sessions, and staffing shortages further exacerbated the issue. Resident 72 and Resident 14 also experienced similar deficiencies, with RNA services not being provided as frequently as ordered. Observations and interviews revealed that these residents were often without necessary splints and supports, and the documentation confirmed missed sessions. The facility's staffing issues, where RNAs were reassigned to CNA duties, contributed significantly to the failure in providing consistent restorative care. The Director of Staff Development and other staff acknowledged the scheduling and documentation issues, which led to residents missing essential RNA programs.
Insufficient Staffing for RNA Services
Penalty
Summary
The facility failed to ensure sufficient staffing to perform Restorative Nursing Assistant (RNA) services and exercises as ordered by physicians for residents with limited range of motion (ROM). On multiple occasions, RNA staff were reassigned to perform Certified Nursing Assistant (CNA) duties due to insufficient CNA staffing, resulting in residents not receiving their prescribed RNA programs. This deficiency was observed through a review of the facility's Daily Staffing Assignments, which showed that on several dates, either no RNA was assigned, or RNAs were reassigned to CNA duties, leaving residents without the necessary RNA services. Interviews with RNA staff and the Director of Staff Development (DSD) confirmed that when the facility was short-staffed, RNAs were often pulled to cover CNA duties. This led to situations where residents did not receive their RNA programs, as RNAs did not work overtime to cover the missed sessions. The DSD acknowledged the importance of having two RNAs scheduled daily to ensure all residents receive their RNA treatments, but admitted that finding coverage was sometimes challenging. The Assistant Director of Nursing (ADON) and the Director of Rehab (DR) also emphasized the importance of having sufficient RNA staff to prevent contractures and improve residents' mobility. The facility's policy on staffing, dated August 2022, indicated that sufficient numbers of nursing staff should be provided to meet residents' needs, but the observed staffing practices did not align with this policy, leading to the deficiency in care for residents requiring RNA services.
Medication Administration Error Due to Improper G-Tube Flushing
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as observed during a medication pass involving a Licensed Vocational Nurse (LVN) and a resident with a gastrostomy tube (G-Tube). The LVN did not flush the G-Tube with water between administering nine medications, resulting in a 33.3% medication error rate. This practice was contrary to the facility's policy, which requires flushing with at least 15 ml of water between medications to ensure safe administration. The resident involved had a history of metabolic encephalopathy and sepsis and was dependent on staff for daily living activities due to severely impaired cognitive skills. The LVN acknowledged the error during an interview, admitting that the lack of flushing could lead to drug reactions that might deactivate the medications. The Assistant Director of Nursing confirmed the correct procedure, emphasizing the importance of flushing to prevent medication errors.
Deficiency in RNA Services Due to Ineffective QAA System
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain an effective system to identify, monitor, and evaluate the implementation of a plan of correction for a previously cited deficiency. This deficiency, initially identified on 8/1/2024, was related to insufficient staffing of Restorative Nursing Assistants (RNAs) and Certified Nurse Assistants (CNAs) to provide necessary exercises and devices as ordered by physicians to prevent decline in residents' mobility. The deficiency affected 19 residents who were receiving RNA services, putting them at risk for further decline in range of motion, mobility, and contractures. During interviews, the Administrator and Director of Nursing (DON) were unaware of the continued issues related to RNA services, such as RNAs being reassigned to perform CNA tasks and residents not receiving RNA-assisted exercises and services as ordered. The DON admitted that the RNA services program was a collaboration between the Director of Staff Development (DSD) and the Director of Rehabilitation (DOR) services, but they were unaware of incorrect transcription of physician orders into the RNA record in the Electronic Medical Records (EMR) system. The facility's policies and procedures for Quality Assurance and Performance Improvement (QAPI) were reviewed, indicating a lack of effective tracking, measuring, and monitoring of performance, which contributed to the deficiency not being addressed in a timely manner.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its infection control policies and procedures, leading to several deficiencies involving five residents. For Resident 62, the suprapubic catheter drainage bag was found on the floor, which is against the facility's policy that requires catheter bags to be kept off the floor to prevent contamination. The Infection Control Nurse confirmed that the floor is dirty and could lead to contamination, potentially making the resident sick. For Residents 67 and 92, a Certified Nursing Assistant (CNA) did not perform hand hygiene before and after providing care to these residents. The CNA admitted to being too busy and forgetting to perform hand hygiene, which is crucial to prevent the spread of infection. The facility's policy mandates hand hygiene before and after direct contact with residents and handling food, which was not followed in this instance. Resident 78's feeding tubing was observed touching the floor, which poses an infection control risk. The Licensed Vocational Nurse acknowledged that the tubing should not be on the floor due to infection concerns. Additionally, Resident 77's family members were not following Enhanced Barrier Precautions (EBP) while in close contact with the resident, despite the resident being at high risk for infection. The family members were observed not wearing personal protective equipment (PPE) and handling dirty linens without gloves, increasing the risk of spreading multi-resistant drug organisms (MRDO).
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that two residents, Resident 16 and Resident 39, were offered the opportunity to formulate and receive information related to Advance Directives during their initial admission and subsequent re-admission. Resident 16, who has diagnoses including ventilator dependence, epilepsy, and a persistent vegetative state, did not have an advance directive noted in their Physician Orders for Life-Sustaining Treatment (POLST) form. The Social Services Director confirmed that Resident 16 had not been offered an advance directive since their first admission. Resident 39, diagnosed with ventilator dependence, muscular dystrophy, and quadriplegia, also did not have an advance directive on file. The Medical Records Director noted the absence of a signed Advance Healthcare Directive Acknowledgement (AHDA) form in Resident 39's medical record. Although the Social Services staff discussed advance directives with Resident 39, the AHDA form remained unsigned as Resident 39 wished to wait for a family member to sign on their behalf. The Social Services Director acknowledged that information regarding advance directives should have been provided to Resident 39 and their responsible party during the initial admission.
Failure to Transmit Discharge MDS Timely
Penalty
Summary
The facility failed to ensure the timely transmission of the Discharge Minimum Data Set (MDS) to the Centers for Medicare and Medicaid Services (CMS) for one resident, identified as Resident 87. This deficiency was identified during a review of Resident 87's records, which showed that the resident was originally admitted on January 30, 2024, and readmitted on July 14, 2024, with diagnoses including metabolic encephalopathy, heart failure, diabetes mellitus, and hyperlipidemia. The resident was discharged to an Assisted Living Facility on August 30, 2024, but the discharge MDS was not completed or transmitted within the required 30-day period. During an interview, the Minimum Data Set Nurse (MDSN) admitted to forgetting to complete the discharge MDS for Resident 87. The Director of Nursing (DON) emphasized the importance of completing and submitting all MDS assessments on time to ensure accurate reporting to CMS. The facility's failure to complete and transmit the discharge MDS in a timely manner had the potential to affect the quality-of-care monitoring system, which is crucial for ensuring safe and efficient resident-centered care.
Failure to Follow G-Tube Medication Administration Protocol
Penalty
Summary
The facility failed to adhere to professional standards of practice in nursing care for Resident 86 by not checking for gastric residual volume before administering medications via a Gastrostomy Tube (G-Tube) and not flushing the G-Tube with water between each medication. During a medication pass observation, a Licensed Vocational Nurse (LVN) was seen administering medications to Resident 86 without checking for residuals and without flushing the G-Tube with water between medications. This practice was contrary to the facility's policy, which requires flushing with at least 15 mL of water before and between medications, and checking for residuals to ensure proper digestion and reduce the risk of complications. Resident 86, who was admitted to the facility with diagnoses including metabolic encephalopathy and sepsis, had severely impaired cognitive skills and was dependent on staff for daily living activities. The facility's policy on administering medications through an enteral tube emphasizes the importance of verifying tube placement and flushing with water to prevent complications such as aspiration and clogged tubes. The Assistant Director of Nursing (ADON) confirmed the necessity of these procedures, highlighting the potential for drug interactions and the importance of proper medication administration techniques.
Failure to Implement Bowel and Bladder Training Leads to Resident Fall
Penalty
Summary
The facility failed to initiate routine bowel and bladder training programs for a resident, identified as Resident 198, who was assessed as being at high risk for falls. Resident 198, who was admitted with diagnoses including spinal stenosis and lack of coordination, required partial assistance for activities of daily living, including toileting. Despite being identified as high risk for falls due to factors such as intermittent confusion, poor safety awareness, and a history of falls, the facility did not implement a bowel and bladder toileting program for the resident. On the day of the incident, Resident 198 was observed walking out of his room and falling over a plastic wet floor sign placed in front of his room. The resident was attempting to use the restroom unassisted, which led to the fall. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that Resident 198 was not on a bowel and bladder training program, despite having episodes of continence and incontinence and being able to make his needs known. The staff acknowledged that such a program should have been initiated after the resident's second fall in the facility. The facility's policy and procedure for behavioral programs and toileting plans for incontinence, which includes bladder rehabilitation and toileting plans, was not followed for Resident 198. The failure to implement these programs contributed to the resident's fall, as the resident attempted to find a restroom without assistance. The incident highlights the facility's oversight in addressing the resident's toileting needs and ensuring a safe environment to prevent falls.
Inadequate Supervision and Hazardous Environment Lead to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures to prevent a fall for a resident identified as high risk for falls. The resident, who had a history of falls and was diagnosed with spinal stenosis and lack of coordination, was observed falling over a plastic Wet Floor sign placed in front of his room. The resident's care plan indicated a need for frequent supervision and monitoring due to his unsteady gait and balance issues. However, during the incident, the Licensed Vocational Nurse (LVN) responsible for monitoring was on the other side of the station, preparing to pass medication, and was not present to prevent the fall. The housekeeper had placed the Wet Floor sign in front of the resident's door after mopping, intending to alert others of the wet floor. However, this action inadvertently created a hazard for the resident, who was known to have poor safety awareness and an unsteady gait. The Director of Nursing acknowledged that the environment should be free of clutter and hazards, especially for high fall-risk residents, and that the placement of the Wet Floor sign was inappropriate in this context. The facility's policy emphasized the importance of maintaining a safe environment and providing supervision to prevent accidents, which was not adhered to in this instance.
Inadequate Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate assessments, treatments, and services for a resident who was incontinent of bladder and had an indwelling Foley catheter for wound care management. The resident's Foley catheter was not properly secured to her leg, which could lead to dislodgement and potential trauma. Additionally, sediment was observed in the urine, indicating a possible urinary tract infection (UTI), but there was no documentation of the urine's color and consistency for a month. The resident was admitted with diagnoses including respiratory failure, a stage 4 pressure ulcer, and sepsis. The care plan included monitoring for signs of UTI and maintaining proper catheter alignment. However, during observations, the catheter was found unstrapped and with sediment, and there was no evidence of catheter flushing as ordered. Interviews with staff revealed that the licensed nurses were responsible for assessing the urine characteristics and ensuring the catheter was properly secured, but these actions were not consistently documented or performed. The facility's policy required immediate reporting of unusual findings to a physician, but there was no documented change of condition evaluation for the sediment in the catheter. The Assistant Director of Nursing confirmed that sediment in the catheter was not normal and should have been reported to the physician. The facility's failure to adhere to its policies and procedures for catheter care and change in condition reporting contributed to the deficiency.
Failure to Use Alternatives Before Side Rails
Penalty
Summary
The facility failed to use appropriate alternative interventions before installing bilateral upper half side rails for a resident, identified as Resident 298. The resident was admitted with acute respiratory failure, hemiplegia, hemiparesis, and was receiving surgical aftercare. The facility's documentation indicated that side rails were used due to the resident sliding down in bed, related to an elevated head of bed for tube feeding. However, there was no documented evidence of alternative interventions being attempted prior to the use of side rails. The informed consent document for the use of side rails was incomplete, lacking a physician's signature and only indicating verbal consent from the resident, who was noted to lack the capacity to understand and make decisions. The facility's assessment and care plan documents also failed to show any attempts at alternative measures before resorting to side rails. Observations confirmed the use of side rails, and interviews with staff revealed a practice of automatically placing residents on side rails upon admission, without documented evidence of alternative interventions. The facility's policy required attempts to use alternatives before side rails, but this was not followed. Interviews with staff, including a CNA, LVN, and RN, indicated a lack of documentation and monitoring for side rail use, and the ADON confirmed that alternatives were not attempted. The facility's failure to adhere to its own policies and procedures regarding bed safety and side rail use resulted in a deficiency, as it did not ensure the safety and proper assessment of the resident's needs before implementing side rails.
Failure to Complete Annual Competency Assessments for Staff
Penalty
Summary
The facility failed to ensure that one Licensed Vocational Nurse (LVN 2) and one Certified Nursing Assistant (CNA 3) completed their annual competency assessments and evaluations. LVN 2 was hired on April 3, 2020, and their competency checklist was dated November 17, 2023, indicating a lapse in the annual assessment for the previous year. Similarly, CNA 3, hired on January 28, 2005, had a competency checklist dated December 3, 2023, also showing a failure to complete the annual assessment in 2024. During interviews, the Director of Nursing (DON) acknowledged that all licensed nurses should complete competency skills upon hire and annually, but was unaware of why LVN 2's assessment was not completed the previous year. The Director of Staff Development (DSD) confirmed that competency evaluations are conducted via written tests and return demonstrations upon hiring and annually for all staff, but could not explain why CNA 3's assessment was not completed in 2024. The facility's policy, revised in August 2022, states that the facility provides sufficient numbers with the appropriate skills and competency necessary to provide nursing-related care and services for all residents.
Failure to Conduct Required Joint Mobility Assessments
Penalty
Summary
The facility failed to provide required specialized rehabilitation services for a resident, specifically in the area of joint mobility assessments. Resident 14, who has diagnoses including hemiplegia and diabetes mellitus, was not assessed for potential joint mobility concerns annually and quarterly as required. The last documented occupational therapy (OT) joint mobility screening for the resident was completed in 2022, and no subsequent screenings were found in the resident's medical record for 2024. This oversight was acknowledged by the Director of Rehab, who confirmed that the annual physical therapy (PT) joint mobility assessment for 2024 was missed, and the last OT assessment was completed in 2022. The Director of Nursing emphasized the importance of joint mobility assessments in preventing contractures and maintaining residents' functional independence. The facility's policy requires joint mobility assessments to be conducted upon admission, readmission, and annually, in conjunction with the Minimum Data Set (MDS) assessment schedule. The failure to conduct these assessments as per policy was identified during a review of the facility's policy and procedure, which mandates that joint mobility screenings be completed by PT and/or OT. This deficiency had the potential to negatively impact the resident's physical and mobility function.
Failure to Explain Arbitration Agreement to Resident's Responsible Party
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to the responsible party of a resident, identified as Resident 198, who was admitted with diagnoses including dementia and cognitive communication deficit. The responsible party, listed as Family Member 1, reported not understanding the arbitration agreement or the rights to make informed decisions about the resident's care. Despite signing the arbitration documents, Family Member 1 stated that the forms were handed over without explanation, and she was not informed about the meaning of the arbitration agreement. The Admissions Coordinator indicated that the arbitration information document was self-explanatory and that the responsible party could read it themselves, but was not allowed to answer any questions. The Administrator acknowledged that the arbitration agreement should have been explained in a manner that the responsible party could understand, as per the State Operations Manual Appendix PP. The failure to ensure comprehension of the arbitration agreement resulted in the responsible party being unable to make an informed decision regarding the resident's care.
Non-Operational Call Light System for Multiple Residents
Penalty
Summary
The facility failed to maintain a functioning call light system for three residents, which was identified during an observation and interview process. Resident 5, who has chronic obstructive pulmonary disease and Alzheimer's disease, was unable to alert staff for assistance due to a non-operational call light. Despite having the call light in hand and pressing it repeatedly, the system did not signal at the nurse's station or outside the room. Similarly, Residents 48 and 62, both with conditions affecting mobility and communication, were also found to have non-functioning call lights, preventing them from effectively requesting assistance. The issue was confirmed during an interview with the Assistant Director of Nursing and the Infection Preventionist Nurse, who verified that the call lights for all three residents were not functioning properly. The Maintenance Supervisor later stated that the malfunction had not been reported to the maintenance department, despite daily checks being conducted. The Director of Nursing emphasized the importance of operational call lights for resident safety and timely care, as outlined in the facility's maintenance policy.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that resident bedrooms met the required minimum size of 80 square feet per resident in multiple resident rooms. Specifically, 11 out of 39 resident rooms were found to be below this standard, with rooms 5, 6, 8, 9, 11, 12, 14, 15, 16, 17, and 18 measuring less than the required square footage per resident. This deficiency was identified through observation, interviews, and record reviews, which revealed that the rooms did not meet the necessary space requirements for safe nursing care and resident privacy. Despite the deficiency, interviews with residents and staff indicated that the current room sizes did not adversely affect the residents' care or their ability to move freely. Residents reported that they could ambulate and transfer without issues, and staff confirmed that they could provide care by adjusting furniture to create necessary space. The facility's variance request suggested that the room sizes did not negatively impact residents' health, safety, or well-being.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to accommodate the needs of four residents by not responding to call lights in a timely manner. Resident 1, who was admitted with hemiplegia affecting both sides of the body and had moderately impaired cognition, reported that it took at least two hours for staff to respond to his call light. Resident 3, who was dependent on assistance for daily activities, also experienced delays of 1-2 hours during the night shift for diaper changes. Resident 4, with intact cognition but requiring moderate assistance, reported similar delays during the night shift. Resident 5, who required substantial assistance due to a fibula fracture, experienced delays of at least an hour for diaper changes, leading to feelings of neglect and discomfort. The Resident Council Meeting minutes indicated that residents had previously voiced concerns about the untimely response to call lights. The Director of Staff Development confirmed that call lights should be answered within five minutes, as per the facility's policy. However, the facility's failure to adhere to this policy resulted in increased risk for harm to the residents, as they were left waiting for assistance with personal hygiene and other needs.
Failure to Follow Influenza Vaccination Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure for influenza immunization for one of the residents. The resident, who was admitted with acute respiratory failure and cerebral aneurysm, was not properly offered the influenza vaccine. The facility did not provide the necessary education regarding the benefits and potential side effects of the vaccine, nor did it document the resident's refusal with the required name and signature on the Vaccine Consent Form. This oversight was identified during a review of the resident's records and interviews with the staff and the resident. The Licensed Vocational Nurse (LVN) claimed to have offered the influenza and Covid-19 vaccines to the resident, who allegedly refused them. However, the resident denied this, stating that the nurse did not present a Vaccine Consent Form or discuss the risks and benefits. The Director of Nursing (DON) confirmed that the facility's policy requires residents to sign a refusal form with two witnesses if they decline vaccination. The facility's policy also mandates that residents be informed and educated about the vaccine's benefits and side effects, which was not followed in this case.
Failure to Offer and Document Covid-19 Vaccine for Resident
Penalty
Summary
The facility failed to adhere to its Covid-19 policy and procedure for a resident by not offering the Covid-19 2024/2025 vaccine, not providing education about the vaccine's benefits and risks, and not properly documenting the resident's refusal. The resident, who was admitted with acute respiratory failure and a cerebral aneurysm, had moderately impaired cognition and required substantial assistance with daily activities. Despite a Vaccine Consent Form indicating refusal, it lacked the resident's name and signature, and the resident later tested positive for Covid-19. Interviews revealed discrepancies in the facility's handling of the vaccine offer. A Licensed Vocational Nurse claimed to have offered the vaccine, which the resident allegedly refused, but the resident denied this, stating they were not shown a consent form or informed about the vaccine's risks and benefits. The Director of Nursing confirmed the facility's policy of offering vaccines and requiring a signed refusal form with witnesses if declined. However, the facility's failure to document the refusal properly and provide education as per policy led to the deficiency.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its policies and procedures regarding the prevention of abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified when a resident expressed discomfort with a male Certified Nursing Assistant (CNA) providing pericare, yet the facility did not investigate or report the incident as required by federal regulations. The resident had informed a Registered Nurse (RN) that she did not want the male CNA to provide care, but the CNA was assigned to her again the following day, which made the resident feel unsafe. The resident, who was admitted with diagnoses including acute chronic respiratory failure and severe cognitive impairment, was dependent on facility staff for personal care. Despite the resident's clear preference for female CNAs, the facility's staffing assignments did not reflect this preference, leading to the same male CNA being assigned to her care again. The Assistant Director of Nursing (ADON) was only informed of the resident's preference after the CNA had been reassigned, indicating a breakdown in communication and adherence to the facility's abuse prevention policies. Interviews with facility staff revealed that the RN who was initially informed of the resident's discomfort did not report the incident to the Director of Nursing (DON) or the Administrator, who is the abuse coordinator. Additionally, the Director of Staff Development (DSD) was unaware of the resident's preference when making staffing assignments. The facility's policies require immediate reporting and investigation of any allegations of abuse, but these procedures were not followed, resulting in the resident's continued distress and the facility's failure to protect her from potential abuse.
Failure to Document Resident's Belongings Leads to Loss
Penalty
Summary
The facility failed to document a resident's belongings, specifically a rosary, leading to its loss. The resident, who had severe cognitive impairment and was dependent on facility staff for personal care, was admitted and readmitted with various diagnoses, including anoxic brain damage. During the resident's stay, a family member reported that the rosary, given by a priest, was missing after the resident was transferred to a different care unit. The facility's inventory list did not include the rosary, although it was acknowledged by a CNA that the resident had it along with other personal items. Interviews with facility staff, including a CNA, LVN, DON, and SSD, revealed that the facility's policy required new items to be documented on the inventory list, but this was not done for the rosary. The DON stated that items from church services were not typically documented, which contributed to the oversight. The facility's grievance report confirmed the missing items and noted attempts to contact the family for descriptions to replace them. The facility's policy emphasized the importance of documenting personal belongings upon admission and updating the inventory as necessary.
Failure to Follow Up on Dental X-ray Recommendation
Penalty
Summary
The facility failed to provide medically related social services for a resident by not following up on a dentist's recommendation for an x-ray to evaluate an aching tooth. The resident, who was admitted and readmitted to the facility with diagnoses including anoxic brain damage and severe cognitive impairment, was dependent on staff for personal care. The dentist recommended an x-ray to confirm the source of the resident's pain, but the x-ray was not performed as of the review date. Interviews with facility staff revealed a breakdown in communication and responsibility. The Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) both stated they were unaware of the dentist's recommendation for an x-ray. The Social Services Director (SSD) acknowledged that it was their responsibility to follow up on dental recommendations, but the recommendation for the x-ray was missed. The facility's policy indicated that social services staff were responsible for obtaining needed services, but this was not executed, potentially leading to the resident experiencing pain and further dental issues.
Deficient Infection Control Practices in Linen Handling
Penalty
Summary
The facility failed to adhere to its infection prevention and control practices, specifically in the handling and storage of dirty linen, which affected six residents. The deficiency was identified during a survey where it was found that dirty linens, including those from isolation rooms, were not being managed according to the facility's policy. Certified Nursing Assistant (CNA) 1 reported that isolation linens were placed in single black bags without being double-bagged or labeled, which could lead to cross-contamination and the spread of infection. Interviews with the Laundry Personnel (LP) revealed that isolation linens were supposed to be double-bagged and labeled with the resident's room and bed number to distinguish them from regular dirty linens. However, the LP noted that both types of linens were placed in black bags, and without proper labeling or double-bagging, it was challenging to identify isolation linens, increasing the risk of infection spread. The Director of Nursing (DON) stated that all linens were considered dirty and that the washing process should eliminate microorganisms, but this did not align with the facility's policy for handling isolation linens. The facility's policies on standard precautions, laundry handling, and infection control emphasized the need for proper handling and processing of soiled linens to prevent contamination and the spread of infections. Despite these policies, the facility's practices did not ensure that isolation linens were managed in a manner that prevented the transfer of microorganisms, as required by their infection control program. This oversight had the potential to increase the spread of infections within the facility.
Failure to Notify Physician After Resident Fall
Penalty
Summary
The facility failed to notify the physician after a resident fell from a shower chair on August 1, 2024. This incident involved a resident who was admitted to the facility on January 25, 2019, and readmitted on August 9, 2024, with diagnoses including muscle weakness, osteoarthritis of the left ankle and foot, and unspecified dementia. The resident was moderately impaired cognitively and required supervision during showering. Despite the fall, there was no documented evidence in the resident's electronic medical chart indicating that the physician or the responsible party was notified of the incident. During an interview, the Assistant Director of Nursing (ADON) stated that he was unaware of the fall until August 15, 2024, and confirmed that there was no documented evidence of a Change of Condition assessment, SBAR Communication Form, skin assessment, 72-hour neurological checks, or an interdisciplinary team meeting conducted after the fall. The facility's policy and procedure require prompt notification of the resident's attending physician and representative in the event of an accident or incident, which was not followed in this case.
Failure to Update Care Plans for Residents with Falls and Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. For the first resident, who had a history of falls and was at risk due to muscle weakness, osteoarthritis, and dementia, the facility did not document a fall that occurred on 8/1/2024. Despite the resident's care plan indicating a risk for falls and requiring frequent supervision, the plan was not updated after the fall incident. The Assistant Director of Nursing acknowledged that the care plan was not revised to address the fall and prevent future incidents. The second resident, who had acute respiratory failure, cerebral palsy, and Type 2 Diabetes Mellitus, was involved in a grievance related to disruptive behavior in their shared room. The facility's records showed a grievance about the resident's behavior of playing with privacy curtains and having the television volume too loud, which disturbed another resident. Although the facility recommended that nursing supervisors conduct rounds to monitor safety and noise levels, these recommendations were not documented in the resident's care plan. Nursing staff were unaware of the need to monitor the behavior and noise levels, as the care plan was not updated to reflect these concerns. The facility's policy on care plans requires ongoing assessments and updates when there are significant changes in a resident's condition. However, in both cases, the care plans were not revised to address the incidents and recommendations, leading to potential risks for the residents involved. The lack of documentation and communication among staff contributed to the deficiencies in care planning and implementation.
Inadequate Pressure Ulcer Care Due to Insufficient Supplies
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for two residents. Resident 1, who was admitted with a stage 4 pressure ulcer in the sacral region, had a care plan that included specific interventions such as administering treatment as ordered and monitoring for signs of infection. However, during incontinent care, the facility did not follow its policies and procedures, which included using appropriate materials to clean the resident. Instead, a reusable washcloth was used, which was rough and could potentially cause skin irritation or tears. Resident 2, who had a stage 3 pressure ulcer, also experienced inadequate care. The care plan for this resident included similar interventions to minimize the risk of complications and promote healing. However, during an observation, a CNA used a reusable washcloth to clean the resident after a bowel movement, which was against the facility's policy. The CNA was unaware of where to find disposable cleansing wipes, which were supposed to be used to prevent skin irritation and promote healing. The facility's supply of disposable wipes was insufficient, as noted during an interview with the Central Supply staff. The facility had recently used a significant portion of its supply due to a water shut-off, and there were concerns about not having enough wipes if the water was shut off again. This lack of supplies contributed to the use of inappropriate cleaning materials, which could hinder wound healing and cause discomfort to the residents.
Failure to Investigate and Address Fall Risk
Penalty
Summary
The facility failed to investigate and implement interventions for a resident with a history of falls, who experienced a recurrent fall on 8/1/2024. The resident, who was admitted with diagnoses including muscle weakness, osteoarthritis, and unspecified dementia, was found to have fallen after attempting to stand from a shower chair without shoes. The resident's Minimum Data Set indicated a need for supervision during certain activities, yet the fall was not documented or investigated, and no interventions were implemented to address the resident's fall risk factors. The incident occurred when a CNA left the resident unattended in a shower chair while moving a wheelchair that was blocking the path to the resident's bed. The CNA heard a noise and found the resident on the floor, having slipped and hit her head. Despite the incident, there was no documentation in the resident's electronic medical chart, and the Assistant Director of Nursing was unaware of the fall until two weeks later. The facility's fall protocol, which includes incident reporting, physician and family notification, and post-fall assessments, was not followed. The facility's policies require thorough documentation and investigation of falls, including assessments of vital signs, neurological status, and pain, as well as an evaluation of precipitating factors. However, these procedures were not adhered to in this case, as there was no evidence of a Change of Condition assessment, SBAR communication, care plan update, or interdisciplinary team meeting following the fall. This lack of action and documentation represents a significant deficiency in the facility's care and supervision of the resident.
Deficiency in Restorative Nursing Assistant Services
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents requiring Restorative Nursing Assistant (RNA) services. Specifically, the RNA, who is a certified nursing assistant with specialized training in rehabilitation skills, was assigned to perform regular CNA duties instead of focusing on RNA-specific tasks such as range of motion exercises. This affected 19 residents on the RNA program, including a resident with a physician's order for RNA-assisted exercises, who reported not receiving these services for the past two months. The resident's medical history includes muscle weakness, functional quadriplegia, and an acquired absence of the left leg below the knee, necessitating regular RNA exercises to maintain mobility and prevent joint stiffness. Interviews with staff revealed that when no RNA was scheduled, CNAs attempted to provide RNA exercises during their regular duties, but this was inconsistent and not in line with specific physician orders. The Director of Staff Development and the Director of Rehabilitation had differing views on whether ADL activities could substitute for RNA exercises, with the latter emphasizing the need for dedicated RNA services. The facility's policy stated that restorative nursing care should be individualized and resident-centered, but the lack of a clear list of residents in the RNA program and the absence of scheduled RNAs led to a failure in delivering these essential services.
Failure to Update and Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was updated and posted in a visible and prominent place, as required. On July 31, 2024, it was observed that the staffing information posted in front of the Subacute Nursing Station was outdated, displaying information from July 25, 2024. This was verified with a Registered Nurse (RN) who explained that the posting was not updated in the morning due to a last-minute change in RN staffing assignments. An RN called off for the Skilled Nursing Facility (SNF) Station, necessitating a reassignment of staff, which delayed the update of the staffing information. According to the facility's policy, direct care daily staffing numbers should be posted for every shift, but this was not adhered to, resulting in the deficiency.
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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 Whittier
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whittier Nursing And Wellness Center, Inc | 0.6 mi | ★★★★★ | 8 | 0 |
| Presbyterian Intercomm Hosp Dp/snf | 0.6 mi | ★★★★★ | 0 | 0 |
| The Orchard - Post Acute Care | 0.6 mi | ★★★★★ | 3 | 0 |
| Socal Post-acute Care | 1.8 mi | ★★★★★ | 22 | 0 |
| Whittier Hospital Medical Ctr D/p Snf | 2.4 mi | ★★★★★ | 1 | 0 |
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