Accel At Longmont Health And Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Longmont, Colorado.
- Location
- 1960 S Fordham St, Longmont, Colorado 80503
- CMS Provider Number
- 065429
- Inspections on file
- 29
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 49 (1 serious)
Citation history
Health deficiencies cited at Accel At Longmont Health And Rehab, Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, and a known history of alcohol use left the facility and was later found outside yelling for help and lying on the ground. Police identified the individual, determined the resident was intoxicated, and returned him to the facility, where he required wheelchair transport to his room despite normally walking without assistive devices. Officers helped the resident into bed, but nursing staff did not complete a change of condition assessment, obtain vitals, perform a head-to-toe or post-fall evaluation, or document his condition or monitoring afterward. The physician and legal guardian were not notified of the intoxication or change in condition, and there was no care plan addressing alcohol use or intoxication despite existing orders to monitor for substance use and notify the provider. A few hours later, a CNA found the resident face down on the floor, unresponsive, and he was pronounced dead, with the death certificate citing respiratory failure, aspiration event, and alcoholism; the incident was not promptly reported or thoroughly investigated at the time.
A resident with CHF and multiple comorbidities was readmitted from the hospital with an order for metolazone 2.5 mg PRN, to be given only when weight increased by 5 lbs over baseline and 30 minutes before Lasix. Due to incorrect transcription of the hospital discharge orders into the EMR by the ADON, and the absence of a required second-nurse verification, metolazone was entered and administered as a scheduled daily medication instead of PRN. Nursing staff gave the drug daily for eight days without confirming the weight-based parameter, including on days when no weight was obtained and when the resident’s weight was stable or decreasing. During this period, the resident experienced a 12–14 lb weight loss, marked weakness, fatigue, excessive somnolence, and was later found to have hypokalemia, while continuing on other diuretics (Lasix and spironolactone). Interviews with the resident, her representative, nursing staff, the DON, PCP, and pharmacist linked these changes to the medication error, which did not follow the prescriber’s PRN order or the facility’s medication error policy.
The facility failed to maintain a full-time RN DON when the existing DON was reassigned as a temporary emergency NHA, leaving no separate RN designated to the DON role. Records showed the acting NHA held a temporary administrator permit while the staffing list indicated no full-time DON in place, despite a job description assigning the DON responsibility for 24-hour nursing oversight, staffing, and key clinical systems. Staff interviews revealed that nurses were unaware of the DON’s reassignment and continued to view this person as their direct supervisor, while the acting NHA reported performing both administrative and DON functions, including abuse coordination and state occurrence reporting, without any formal announcement or signage to inform staff, residents, or families of these role changes.
The facility’s QAPI program failed to identify and address critical quality of care issues related to resident change in condition, despite a written policy requiring comprehensive, data‑driven performance monitoring and corrective action. The facility had repeat F684 citations for quality of care and, in the current survey, was found to have not adequately assessed, monitored, documented, or communicated a resident’s change in condition, which was associated with the resident’s death and resulted in an immediate jeopardy finding. The MD reported he reviewed only those cases and policies presented to him and was unaware that the DON was also serving as the temporary emergency NHA amid leadership changes. The DON/acting NHA stated that QAPI meetings focused on standard topics and that change of condition evaluations were limited mainly to skin alterations and falls, acknowledging that staff were new to other types of change of condition assessments requiring thorough evaluation and provider/family notification.
Staff failed to follow infection prevention protocols, including not changing gloves or performing hand hygiene between catheter care and incontinence care for a resident with wounds and an indwelling device. A shared shower chair was not cleaned after use and was visibly soiled before being used again. Additionally, the facility's main water heater was broken, resulting in laundry being washed at insufficient temperatures and in areas lacking proper infection control measures, with no physical separation from resident spaces.
A resident with chronic respiratory conditions and moderate cognitive impairment was allowed to keep and self-administer an albuterol inhaler without a documented assessment or physician's order authorizing self-administration. Staff interviews confirmed that required assessments and documentation were missing from the medical record, and the care plan did not reflect the resident's ability to self-administer medication.
Surveyors found that two linen storage closets lacked essential clean linens, such as fitted sheets and pillowcases. Two residents reported frequent shortages, and staff—including a CNA and the laundry aide—confirmed that the facility did not maintain an adequate linen supply, requiring them to rotate and prioritize available items to meet resident needs. Facility leadership acknowledged the ongoing linen shortage and its impact on maintaining a safe and comfortable environment.
A resident with a history of behavioral disturbances physically grabbed another resident's arm after a dispute over a sugar packet in the dining room, resulting in visible injuries. Despite a care plan requiring one-to-one supervision, the resident was left unsupervised for several minutes, allowing the incident to occur. Staff and family interviews confirmed lapses in supervision and documentation showed the injuries sustained.
Two residents requiring BiPAP and CPAP therapy did not receive appropriate respiratory care due to lack of proper device setup, missing or incomplete physician's orders, and insufficient staff training. One resident was unable to use his BiPAP machine for an extended period because settings were not adjusted by a physician, and his care plan lacked necessary details. Another resident's CPAP orders were not documented until the time of survey, and staff were not adequately trained on respiratory device care.
Surveyors found that confidential resident information was left unsecured in open bags at the nurse's station for several weeks due to the lack of shred box containers. Additionally, a medication cart was left unattended in a hallway with its computer screen displaying a resident's medication administration record, visible to anyone passing by. Staff confirmed these lapses in maintaining the privacy and confidentiality of residents' medical records.
The facility did not adequately promote or facilitate resident self-determination, resulting in a failure to support resident choice as required. This was due to actions or omissions by staff that did not encourage or honor the resident's right to make decisions about their care or daily activities.
Two residents in the facility developed severe pressure injuries due to the facility's failure to provide timely and necessary treatment. One resident, with diabetes and kidney disease, developed deep tissue injuries and sepsis after the facility did not implement care plan interventions or notify the physician of heel discoloration. Another resident, with a history of vascular disease, developed deep tissue injuries on his foot and heel, leading to cellulitis and sepsis, due to the facility's failure to off-load heels and document skin condition changes. The facility's systemic failure created an immediate jeopardy situation.
The facility failed to employ a qualified infection control preventionist (ICP) with specialized training, affecting all residents. The acting ICP, also the wound care nurse, had not completed her certification, and the regional nurse consultant was unaware of this. This deficiency was identified during a survey.
The facility did not have a full-time RN designated as the Director of Nursing (DON) after the previous DON resigned. Staff interviews revealed that there was no charge nurse on duty, and nursing staff deferred questions to LPNs who were not in management positions. The nursing home administrator confirmed the vacancy and stated that corporate support was assisting until the position could be filled.
The facility reported a medication error rate of 16.67%, exceeding the acceptable threshold. Errors included incorrect application of lidocaine patches, failure to verify vital signs before administering metoprolol, and late administration of Parkinson's medication. Staff interviews confirmed the importance of adhering to prescribed medication guidelines.
The facility failed to follow proper infection prevention practices during medication administration and patient care. An LPN did not perform hand hygiene before or after administering medications and failed to clean a pulse oximeter before and after use. Another LPN prepared medications without hand hygiene, and a staff member disposed of a pill from the floor without performing hand hygiene. The wound care nurse confirmed the importance of hand hygiene and equipment cleaning to prevent infection spread.
The facility failed to properly store and label medications, leaving multi-dose medications unlabeled and a resident's inhaler improperly stored. Medications were left unsecured when an LPN left a cart unattended with keys in the lock. Improper disposal of medications was noted, with unused drugs discarded in trash cans instead of using drugbuster bottles. The medication storage room was cluttered and unclean, with expired medications and a dirty refrigerator. Staff interviews revealed unclear responsibilities for cleaning and medication disposal.
The facility's QAPI program failed to address compliance concerns, leading to repeat deficiencies in medication administration and infection control. A resident developed a wound infection with sepsis due to inadequate pressure injury assessment and treatment. The new NHA was unaware of these issues and could not locate previous documentation, indicating a lack of oversight and continuity.
A resident's electric tricycle was stolen from a locked area in the facility, and the facility failed to replace or reimburse the resident. The tricycle was not listed on the resident's inventory sheet, and the facility lacked a policy for personal property responsibility. The resident filed a grievance, but the facility's corporate management did not authorize reimbursement for the tricycle, valued at $4,000.
A resident with osteomyelitis required IV antibiotics through a PICC line, but the nursing staff removed the line prematurely without a physician's order, leading to missed doses. The error was not reported promptly, delaying the line's replacement. Additionally, the facility failed to change the PICC line dressing as ordered, risking infection. Staff interviews revealed a lack of clarity on PICC line care and the importance of timely reporting and replacement.
The facility did not conduct required annual performance reviews for two CNAs, as identified through record reviews and staff interviews. The HR director and regional nurse consultant confirmed the oversight, acknowledging that the reviews were not completed within the mandated timeframe.
The facility failed to honor the preferences of two residents regarding their care and scheduling. One resident was not assisted in scheduling a wound care appointment at an in-network clinic, leading to financial strain, while another resident's shower preferences were ignored, with no documentation of their requests. Staff interviews revealed a lack of communication and adherence to the facility's policy on residents' rights.
A resident with severe cognitive impairments and multiple diagnoses frequently refused medications and treatments, but the facility failed to update the care plan to address these refusals. Despite known refusals of medications like Aspercreme and Haloperidol, and refusal to be moved to a chair for meals, the care plan lacked person-centered interventions. Staff interviews confirmed awareness of refusals but highlighted a deficiency in care management due to the lack of updated strategies in the care plan.
A resident with multiple diagnoses, including severe cognitive impairments, did not receive showers as per her preference and care plan. Despite her grievance, there was no documentation of showers being offered since her admission. Staff interviews revealed that showers were scheduled by room number, not resident preference, and staff were unaware of the resident's shower status. The regional nurse consultant acknowledged the grievance and the need for timely showers.
The facility failed to ensure two CNAs received required training in abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics, and resident rights. Additionally, there was no documentation of the CNAs completing at least 12 hours of annual in-service training. Interviews with the HRD and RNC confirmed the lack of training completion and documentation.
Failure to Assess and Respond to Resident Intoxication and Change in Condition Resulting in Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with multiple complex medical conditions received treatment and care in accordance with professional standards of practice following a clear change in condition related to alcohol intoxication. The resident had diagnoses including alcoholic polyneuropathy, history of traumatic brain injury, CHF, type 2 diabetes mellitus, alcoholic cirrhosis of the liver, hypertension, long-term anticoagulant use, and alcohol use with an unspecified alcohol-induced disorder. His MDS showed severe cognitive impairment and functional dependence for many ADLs, though he typically ambulated without a mobility device. Physician orders included monitoring for potential substance use each shift and documenting and notifying the physician if any substance use indicators were noted, but the January TAR documented no substance use behaviors for that month. On the day of the incident, the resident signed out of the facility in the morning and was later found outside the facility grounds by bystanders, yelling for help and lying on the ground near a hotel with a shopping cart. Police dispatch records show multiple calls reporting the resident on the ground and yelling for help, and the police ultimately identified him and returned him to the facility. The police reported to staff that the resident was intoxicated and had been wandering. Upon return, he required wheelchair transport from the front door to his room, despite normally walking without assistive devices. According to an IDT note, officers assisted him in removing his shoes and coat and helped him into bed, after which he was observed resting in his room, but no time or assessment details were documented. Record review revealed no documentation that nursing staff completed a change of condition assessment, a post-fall or post-ground-level event assessment, or any RN assessment when the resident was returned by police in an intoxicated state. There was no documentation of vital signs, head-to-toe assessment, skin evaluation, or monitoring between the time of his return and the time he was later found unresponsive. The physician and the resident’s legal guardian were not notified of his intoxication or change in condition, and there was no progress note describing his condition upon return or how he was transferred to bed. The resident’s comprehensive care plan contained no care plan addressing alcohol use, intoxication, or potential substance use, and there were no interventions related to his known history of alcohol abuse and drinking while away from the facility. Staff interviews, including with the DON/acting NHA, ADON, and RNs, confirmed that no change of condition assessment, vital signs, or physician/guardian notifications were completed despite their own descriptions of what should occur when a resident returns intoxicated. The resident was later found face down on the floor in his room, unresponsive, and was pronounced dead; his death certificate listed respiratory failure, aspiration event, and alcoholism as the causes of death. The facility also failed to promptly recognize and investigate the incident as an unexpected death associated with a significant change in condition. A frequent visitor reported that the DON/acting NHA initially did not believe an occurrence report was required for the resident’s intoxicated return and unexpected death, and the occurrence report to the state was not submitted until eight days after the death. There was no evidence of an immediate, thorough internal investigation or root cause analysis at the time of the event to determine why nurses did not complete a change in condition assessment or follow the existing physician order to monitor for substance use and notify the physician. Surveyors determined that the facility did not thoroughly assess and monitor the resident’s alcohol use and change in condition, did not document changes, and did not seek medical treatment or notify the physician and guardian when required, and that these failures contributed to serious harm and death for the resident.
Removal Plan
- NHA notified the facility medical director of the incident.
- Nursing supervisors/designees completed physical assessments/interviews on all residents to identify any changes in condition and notified the physician of any noted changes.
- Initiated a look-back audit of current and discharged residents to ensure change-of-condition policy was followed.
- Identified one current resident without a required 72-hour alert monitoring order; educated the assigned nurse regarding timely initiation of the 72-hour alert monitoring order after completing the eINTERACT change-in-condition evaluation.
- Initiated the missing 72-hour change-in-condition alert monitoring order for the identified resident, including nursing assessments and documentation on the TAR and in progress notes each shift for three days per physician-indicated frequency.
- Reviewed resident change-in-condition and notification policies/procedures for clinical accuracy.
- Educated all nursing staff on addressing changes of condition (assessment, monitoring, physician/family notification, orders, and facility policies/procedures); staff were not permitted to work a shift until education was completed.
- Educated new hires (licensed nurses and nurse aides) during orientation on change-of-condition and physician/family notification requirements and facility policies/procedures.
- DON/designee to conduct audits five times per week for three months of the 24-hour report and progress note report to ensure change-of-condition policies/procedures are followed.
- DON/designee to conduct daily nursing staff huddles Monday through Friday to monitor for changes in resident condition.
- Regional director of clinical services and regional vice president to provide clinical/administrative oversight to ensure education and audits are completed and accurate.
- DON educated by the CNO on appropriately addressing changes of condition (assessment, monitoring, physician orders, and facility policies/procedures).
- DON/designee to complete chart audits to verify detailed assessments/documentation and physician/family notification related to changes of condition.
- Regional Director of Clinical Services to visit the facility to provide general oversight and monitoring of the plan.
Failure to Follow PRN Diuretic Order Leads to Significant Weight Loss and Hypokalemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a diuretic, metolazone, was entered and administered as a scheduled daily medication instead of as a PRN medication with specific weight-based parameters. After an acute hospitalization for conditions including acute on chronic CHF, acute respiratory failure with hypoxia, COPD, atrial fibrillation, hypertension, morbid obesity, COVID-19, and MDRO history, the resident was readmitted to the facility. The hospital discharge order specified metolazone 2.5 mg to be taken once daily as needed for pulmonary edema due to chronic heart failure, only when the resident had a weight gain of 5 lbs over baseline, and to be given 30 minutes prior to Lasix. However, when the orders were transcribed into the facility’s EMR on readmission, metolazone was entered as a scheduled daily medication without PRN parameters, and this incorrect order did not match the hospital discharge instructions. The assistant DON, who entered the readmission orders from the hard-copy discharge packet because the phone lines were down and the usual electronic admission process was not used, input metolazone as a daily scheduled medication. The normal process of having two nurses verify and enter orders was not completed; the ADON entered the orders alone, and the second nurse verification did not occur. As a result, nursing staff administered metolazone 2.5 mg daily for eight days, in addition to the resident’s other diuretics (Lasix and spironolactone), without confirming that the resident had experienced the required 5 lb weight gain from baseline. The MAR documented daily administration of metolazone over this period, including on days when no weight was obtained, and on days when the resident’s weight was stable or decreasing rather than increasing. During this time, the resident experienced significant weight loss and symptoms consistent with a change in condition. Weight records showed a decline from approximately 190 lbs prior to hospitalization to 176.6 lbs when the error was identified, reflecting a loss of about 12–14 lbs over a short period. The resident and her representative reported that she became severely weak, excessively tired, and felt she could not regain her strength, with the representative describing the resident as very tired, exhausted, and feeling as though she could not “hang on any longer.” Clinical documentation noted significant weakness, excessive sleepiness during therapy, and that the resident was triggering for significant weight loss. Laboratory testing later showed hypokalemia, with a potassium level of 3.2 mEq/L. Interviews with nursing staff, the DON, the ADON, the PCP, the pharmacist, the resident, and the resident’s representative consistently attributed the resident’s weight loss, weakness, and low potassium at least in part to the erroneous daily administration of metolazone instead of PRN dosing based on weight gain. The facility’s own medication error policy defined a medication error as preparation or administration of medications not in accordance with the prescriber’s order, manufacturer’s specifications, or accepted professional standards, and defined a significant medication error as one that causes resident discomfort or jeopardizes health and safety. In this case, the metolazone order in the EMR did not reflect the prescriber’s PRN order with weight-based parameters, and the medication was administered without verifying the required 5 lb weight gain. The resident’s care plan for diuretic therapy called for administering diuretics as ordered, monitoring for side effects such as fatigue and increased fall risk, and reporting pertinent lab results, including potassium. Staff interviews acknowledged that the error persisted for about eight days, that medication reconciliation was not completed upon readmission, and that the lack of a second nurse verification contributed to the error. The pharmacist and PCP described the effects of metolazone, especially in combination with Lasix, as including electrolyte abnormalities, weight loss, and weakness, and characterized the error as moderate, with the potential to increase electrolyte depletion and require close monitoring.
Failure to Maintain a Full-Time RN Director of Nursing During Temporary NHA Appointment
Penalty
Summary
The deficiency involves the facility’s failure to designate a registered nurse (RN) to serve as the full-time director of nursing (DON) while the existing DON was reassigned to act as the temporary emergency licensed nursing home administrator (NHA). Record review showed that the acting NHA held an active temporary permit for emergency situations beginning on 12/30/25 and expiring on 3/30/26. A staffing list review revealed there was no full-time DON in the building during this period. The DON job description, signed by the DON, specified that the DON’s primary purpose was to plan, organize, develop, and direct nursing operations, ensure quality resident care on a 24-hour basis, oversee recruitment and hiring of licensed personnel, manage nursing schedules, monitor staffing levels, and oversee implementation of nursing service objectives, policies, and procedures, including key clinical systems such as infection prevention and control, psychotropic and controlled substance management, skin and weight systems, risk management, and hospice liaison. Staff interviews confirmed that the individual serving as the full-time temporary NHA was also functioning as the full-time DON, with no other person appointed to the DON role. The chief nursing officer stated that the temporary NHA was also acting as the full-time DON and reported not knowing there was a regulation preventing this. Nursing staff, including an LPN and an RN, reported they were unaware that the DON had been appointed as the temporary NHA and continued to view the DON as their supervisor. The acting NHA described performing both administrative and clinical leadership duties, including occurrence reporting to the state, serving as abuse coordinator and investigator, and leading stand-up meetings, while relying on two unit managers, an LPN assistant DON, and an infection preventionist to assist with clinical duties and audits. There had been no announcement to staff, residents, or families about the acting NHA appointment or her role as abuse coordinator, and there was no signage indicating this responsibility.
Failure of QAPI Program to Address Change in Condition Leading to Immediate Jeopardy
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective, comprehensive, data‑driven QAPI program that identified and addressed quality of care concerns, particularly related to changes in resident condition. The facility’s QAPI policy required ongoing tracking and measuring of performance, identification and prioritization of quality deficiencies, systematic analysis of underlying causes, and development and monitoring of corrective actions, with a focus on resident safety, health outcomes, and high‑risk or problem‑prone areas. Despite this written policy, the facility did not operate its QA program in a manner that prevented repeat deficiencies, as evidenced by prior citations at F684 (quality of care) in consecutive annual recertification surveys. Surveyors found that the QAPI committee failed to identify and address concerns related to quality of care by not ensuring that resident changes in condition were assessed, monitored, documented, and communicated when indicated. This failure rose to the level of immediate jeopardy and was associated with a serious adverse outcome resulting in a resident’s death. The cross‑referenced F684 citation states that the facility failed to provide quality care by not assessing, monitoring, documenting, and communicating a resident’s change in condition when indicated. The facility’s regulatory history showed that F684 had been cited twice previously at a D scope and severity, indicating a potential for more than minimal harm, isolated, without effective QA‑driven prevention of recurrence. Interviews further demonstrated gaps in the QAPI program’s functioning and oversight. The medical director reported he visited at least twice a month, reviewed cases and policies presented to him, and made changes based on what was brought forward in QAPI, but he was not informed that the DON was also serving as the full‑time temporary emergency licensed NHA for several months, and he described multiple leadership changes. The DON/acting NHA stated that QAPI meetings were held monthly and covered standard topics such as admissions, discharges, falls, staffing, abuse, infection control, and grievances, with use of audit tools and tracking spreadsheets. However, she acknowledged that while change of condition evaluations were being done for skin alterations and falls, staff were “new to the other types of change of condition assessments” that required thorough assessment and notification of the physician and family/guardian, and that change of condition evaluations beyond those limited areas had not been a focus of QAPI until after the incident that led to the immediate jeopardy finding.
Infection Control and Laundry Deficiencies Compromise Resident Safety
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program on two of three units, resulting in lapses in hand hygiene, improper use of personal protective equipment (PPE), and inadequate cleaning of shared equipment. Specifically, a certified nurse aide (CNA) did not change gloves or perform hand hygiene after emptying a resident's indwelling urinary catheter and before providing incontinence care. The same CNA also failed to clean a shared shower chair after use, leaving it visibly soiled with stool before it was placed outside the resident's room for use. The resident involved had an indwelling urinary catheter and wounds, and was on enhanced barrier precautions (EBP), as indicated by signage on the door. Staff interviews confirmed that these actions were contrary to facility policy and infection control expectations. Additionally, the facility's main water heater was broken, resulting in laundry being washed at temperatures significantly below the recommended threshold for effective sanitation. The laundry aide reported that the water temperature during wash cycles was only sixty-eight degrees Fahrenheit, well below the CDC-recommended 160 degrees Fahrenheit for hot-water washing. As a result, the facility resorted to laundering some resident clothing and linens in the rehabilitation area, which was not equipped with industrial washers and dryers and lacked proper infection control or isolation measures. There was also no physical barrier separating the laundry area from resident spaces, further compromising infection prevention. Interviews with staff, including the infection preventionist, director of nursing, nursing home administrator, and laundry aide, confirmed awareness of the deficiencies. Staff acknowledged that the facility's infection control and laundry practices did not meet regulatory standards, and that the lack of functioning equipment and proper procedures contributed to the failure to provide a safe, sanitary, and comfortable environment for residents.
Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a proper assessment was conducted to determine the clinical appropriateness of self-administration of medications for a resident with multiple chronic conditions, including chronic respiratory failure, COPD, and moderate cognitive impairment. The resident was observed with an albuterol inhaler at his bedside and reported that staff allowed him to keep and use the inhaler as needed. However, there was no documentation in the electronic medical record of a self-administration assessment or a physician's order permitting the resident to self-administer the inhaler or to keep it at the bedside. The resident's care plan did not reflect the ability to self-administer medication, and the physician's order only specified the medication and dosage, not self-administration privileges. Interviews with staff, including an LPN, RN, and the DON, confirmed that an assessment should have been completed and documented before allowing the resident to self-administer medication. Staff were unable to locate any such assessment in the resident's record, and the DON acknowledged uncertainty about whether the assessment had been completed. The lack of assessment, physician's order, and care plan documentation led to the deficiency in ensuring safe and clinically appropriate self-administration of medication for the resident.
Insufficient Clean Linen Supply for Resident Care
Penalty
Summary
The facility failed to provide clean linens in sufficient quantities for residents, as evidenced by observations of two out of three linen storage closets lacking essential items. Specifically, one closet contained only flat sheets, comforter sheets, pillowcases, and blankets, but no fitted sheets, while another closet had flat sheets, comforter sheets, and blankets, but no pillowcases or fitted sheets. These shortages were directly observed during facility rounds. Interviews with residents confirmed that clean linens were often unavailable or insufficient, with one resident describing the issue as ongoing. Staff interviews further corroborated the deficiency, with a CNA and the laundry aide both stating that the facility did not maintain an adequate supply of linens, requiring staff to rotate and prioritize available items. The maintenance director and the NHA also acknowledged awareness of the linen shortage, noting that it affected the facility's ability to meet regulatory requirements for a safe, sanitary, and comfortable environment.
Failure to Prevent Resident-to-Resident Abuse During Meal Service
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident during a meal service. The incident involved one resident taking a sugar packet from another resident's dining table, which led to the second resident approaching and physically grabbing the first resident's right arm. This altercation was witnessed by the dietary manager, who reported the event to nursing staff. The affected resident was found to have a pinch mark, bruising, and redness on her right arm, as well as a redness mark at the base of her posterior head. The incident and resulting injuries were documented in the resident's medical record, including photographs and a detailed skin assessment. The resident who initiated the physical contact had a history of behavioral disturbances, including yelling, cursing, and throwing objects when served an inappropriate diet texture. However, prior assessments did not document physical or verbal behaviors directed at others. The resident was cognitively impaired and required behavioral interventions as outlined in her care plan. Despite these interventions, the resident was able to approach and physically harm another resident in the dining room. Interviews with staff and the resident's family revealed that the resident responsible for the altercation had previously entered the dining room unattended, even after being placed on one-to-one supervision following the incident. Observations confirmed that the resident was left unsupervised in the dining area for several minutes before staff intervened. The failure to provide continuous supervision as required contributed to the occurrence of the abuse and the resulting injury to the other resident.
Failure to Provide Appropriate Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required the use of BiPAP and CPAP machines. One resident, who had diagnoses including quadriplegia and sleep apnea, reported not using his BiPAP machine for approximately two months due to incorrect settings and lack of physician adjustment. He stated that he had only seen a respiratory therapist once during his stay, and the settings were not corrected at that time. The resident also indicated that staff asked him for the correct settings, which caused frustration as he expected the facility to have this information. The care plan for this resident did not include specific interventions or settings for the BiPAP machine, and there was no documentation of a follow-up pulmonology appointment as recommended by the physician. Another resident, with chronic respiratory failure and sleep apnea, reported independently managing his CPAP machine and receiving minimal assistance from staff. The care plan referenced the use of CPAP and oxygen, but there were no detailed physician's orders for the CPAP machine in the electronic medical record until the time of the survey. This lack of documented orders meant that staff did not have clear guidance on the application and management of the resident's CPAP therapy prior to the survey. Staff interviews revealed that certified nurse aides had not received training on the care of CPAP or BiPAP machines and were unfamiliar with facility policies regarding these devices. The infection preventionist confirmed that staff education on respiratory devices had not yet been provided and emphasized the need for physician's orders with specific settings in the electronic medical record. The director of nursing acknowledged that nurses were responsible for following up on missed pulmonology appointments and ensuring that physician's orders for respiratory devices were in place, but these actions had not occurred prior to the survey.
Failure to Secure and Maintain Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to ensure the secure and confidential storage of residents' personal and medical records, as required by its own policies and HIPAA regulations. Surveyors observed three brown paper bags and one large black trash bag containing confidential resident information left open and unattended at the nurse's station. Staff interviews confirmed that these bags, filled with resident documents, had been at the nurse's station for several weeks due to the absence of designated shred box containers. Staff were instructed to place confidential documents in these bags, and the director of nursing acknowledged that the facility did not have shred boxes at the time of the survey. Additionally, a locked medication cart was found unattended in the hallway with its computer screen visible to passersby, displaying a portion of a resident's medication administration record. Both the regional nurse consultant and a registered nurse confirmed that the screen should not have been visible to the public and that there was a lock button available to secure the screen. These actions and inactions resulted in the failure to maintain the privacy and confidentiality of residents' medical records.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. Specific actions or omissions by the facility staff led to a lack of support for resident autonomy and decision-making.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide timely and necessary treatment and services to prevent and manage pressure injuries for two residents, leading to severe health complications. Resident #85, who had diabetes and kidney disease, was admitted with a stage 2 pressure injury on her coccyx/sacrum and was at moderate risk for further pressure injuries. Despite an assessment on 11/16/23 revealing discoloration on her heels, the primary care physician was not informed until 11/20/23. By then, the resident had developed deep tissue injuries on both heels, cellulitis, and sepsis, requiring hospitalization. The facility did not implement the care plan interventions for turning, repositioning, and off-loading heels, nor did they update the care plan with new interventions after the heel discoloration was noted. Resident #140, with a history of sacral fracture and peripheral vascular disease, was admitted with intact skin but developed a blister on his right foot two days later. The wound care physician later documented deep tissue injuries on his right toe and heel. The facility failed to off-load the resident's heels as per the care plan and did not accurately document the resident's skin condition in daily notes. The resident's condition worsened, leading to cellulitis and sepsis, necessitating ICU care. The facility did not ensure timely physician notification of the resident's condition changes, and the care plan was not updated with appropriate interventions. The systemic failure to provide timely interventions and necessary treatment for pressure injuries created an immediate jeopardy situation, posing a likelihood of serious harm to other residents with similar conditions. The facility's medical director confirmed that the pressure injuries were avoidable if proper care had been provided, indicating that the facility's protocols and care plans were not followed by staff.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified infection control preventionist (ICP) who had completed specialized training in infection prevention and control, which had the potential to affect all residents residing in the facility at the time of the survey. The Centers for Disease Control and Prevention (CDC) guidelines recommend that nursing homes assign individuals with training in infection prevention and control (IPC) to manage the IPC program on-site. However, the facility was unable to provide documentation that the acting infection preventionist, who was also the wound care nurse, had completed the necessary specialized training. During interviews, the wound care nurse confirmed that she was the acting infection preventionist but had not yet completed her certification, although she was enrolled in a training program. Additionally, the regional nurse consultant, who was providing assistance due to the recent departure of the director of nursing, was unaware that the wound care nurse had not completed her IP training. This lack of a qualified infection preventionist involved in the facility's infection prevention and control program was identified as a deficiency during the survey.
Failure to Designate a Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis after the previous DON resigned. A review of the facility's staffing list and assessment revealed the absence of a full-time DON. Interviews with staff, including a licensed practical nurse (LPN) and the minimum data set (MDS) coordinator, confirmed that there was no designated DON or charge nurse on duty. Instead, nursing staff deferred questions to the wound care nurse and the MDS nurse, both of whom were LPNs and not in management positions. The nursing home administrator (NHA) acknowledged the vacancy in the DON position and stated that the facility had been actively searching for a replacement. In the interim, two nurse managers, who were LPNs, were managing the DON duties. The NHA also mentioned that corporate leadership provided support, with a regional clinical support RN present in the building to assist until the position could be filled.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed error rate of 16.67%. During medication administration, an LPN did not apply a prescribed lidocaine patch to the correct location on a resident's body and documented the administration despite not applying it. Another resident was administered a lidocaine patch to an incorrect area, contrary to the physician's order, and the LPN failed to verify the resident's heart rate or blood pressure before administering metoprolol tartrate. Additionally, the LPN documented the administration of a medication that the resident had refused. A third resident received their Parkinson's medication, carbidopa-levodopa, outside the prescribed administration window, which was confirmed as a medication error by a physician assistant. The facility's policy required medications to be administered within a two-hour window, but the medication was given 50 minutes late. Interviews with staff, including a physician assistant and the regional nurse consultant, confirmed the importance of adhering to prescribed medication administration times and locations, particularly for medications with specific timing requirements like Parkinson's medications.
Infection Control Deficiencies in Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention practices during medication administration and patient care. Observations revealed that an LPN did not perform hand hygiene before entering a resident's room, after administering eye drops, or before administering oral medications. The LPN also failed to clean a pulse oximeter before and after use on a resident. Another LPN was observed preparing medications without performing hand hygiene and entered a resident's room without doing so. Additionally, a staff member picked up a pill from the floor and handed it to an LPN, who disposed of it without performing hand hygiene before continuing to prepare medications. Interviews with the wound care nurse, who oversees the facility's infection control program, confirmed that hand hygiene should be performed before administering resident care and medications, especially eye drops, to prevent infection spread. The nurse also stated that vital signs monitoring equipment should be cleaned after each resident use. These observations and interviews highlight the facility's failure to implement appropriate infection prevention measures, as outlined by the CDC and other professional references.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in accordance with professional standards. Observations revealed that multi-dose medications, such as Anoro Ellipta inhalers, Latanoprost eye drops, and SoloStar insulin pens, were not labeled with the date they were opened. Additionally, a resident's used inhaler was improperly stored in a tissue within a medication cart. These lapses in labeling and storage practices were observed in two medication carts, indicating a systemic issue in medication management. The facility also failed to maintain secure access to medications, as evidenced by an LPN leaving a medication cart unattended with the keys in the lock, making the medications accessible to unauthorized individuals. Furthermore, the disposal of unused, wasted, or damaged medications was not conducted in a manner that prevented diversion or accidental exposure. Instances were noted where medications were improperly disposed of in trash cans instead of using the available drugbuster bottles designed for safe disposal. The medication storage room was found to be cluttered, with expired medications and those belonging to discharged residents left on the counter. The refrigerator in the storage room was observed to have a dried brown liquid on the bottom shelf, indicating a lack of cleanliness and organization. Interviews with staff revealed a lack of clarity regarding responsibilities for cleaning and medication disposal, contributing to the deficiencies observed in medication management and storage practices.
Failure in QAPI Program and Resident Care
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program to identify and address compliance concerns related to quality of life and quality of care. The QAPI committee did not address issues such as medication administration errors and infection control, which were identified during a recertification survey. The facility's regulatory record showed repeat deficiencies, including a medication administration error rate above five percent and infection control issues, both cited at an E level scope and severity. Additionally, the facility failed to ensure pressure injuries were assessed and treated timely, leading to a resident developing a wound infection with sepsis, creating an immediate jeopardy situation with actual serious harm. Interviews revealed that the medical director was unaware of a resident's hospitalization due to infected wounds, indicating a lack of communication and oversight. The new nursing home administrator (NHA) had only participated in one QAPI meeting and was not aware of the identified concerns, such as pressure injuries and medication issues. The NHA was unable to locate any investigations or notes from the previous administrator, highlighting a gap in continuity and documentation. Despite submitting a QAPI plan of correction for medication errors, the NHA did not provide evidence of staff education or audits being conducted, further demonstrating the facility's failure to address and rectify the identified deficiencies.
Removal Plan
- Education to all nurses
- Audits for expired, discontinued or missing medications to be completed
Facility Fails to Prevent Theft of Resident's Electric Tricycle
Penalty
Summary
The facility failed to prevent the misappropriation of property for a resident whose electric tricycle was stolen from behind a locked gate. The resident, who was cognitively intact and dependent on supplemental oxygen, had been admitted to the facility and later discharged to another long-term care facility. The resident's inventory sheets did not list the electric tricycle, and a grievance was filed when the tricycle was not replaced or reimbursed by the facility. The facility's administrator stated that they were not liable for the loss, and corporate management did not authorize reimbursement for the tricycle, which was valued at approximately $4,000. Interviews with staff revealed that the previous nursing home administrator had agreed to store the tricycle in a nearby building due to its size. A police report was filed after the tricycle was stolen, but it was not recovered. The current administrator was unaware of the incident, and the facility lacked a policy for personal property responsibility. The resident was offered a few hundred dollars, which was not accepted, and requested an unused electric wheelchair from the facility as a replacement, which was not provided.
Premature PICC Line Removal and Missed Antibiotic Doses
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for a resident who required intravenous (IV) therapy. The resident, who was over 65 years old and had been diagnosed with acute osteomyelitis of the mandible and an inflammatory condition of the jaw, was prescribed a course of IV antibiotics through a peripherally inserted central catheter (PICC) line. However, the nursing staff removed the PICC line prematurely, before the completion of the prescribed antibiotic course, without a physician's order. The removal of the PICC line led to the resident missing three doses of the antibiotic, as documented in the medication administration record. The error was not reported to a physician until several days later, delaying the replacement of the PICC line and the continuation of the antibiotic therapy. The facility's policy did not include specific guidelines for PICC line care, contributing to the oversight. Interviews with staff revealed a lack of clarity regarding the necessity of a physician's order for PICC line removal and the importance of timely notification and replacement in case of an error. Additionally, the facility failed to adhere to the physician's orders for PICC line dressing changes, as the dressing was not changed every seven days as required. This oversight was noted in the medication administration record, with missed dressing changes on specific dates. Staff interviews highlighted the importance of regular dressing changes to prevent infection at the insertion site and the need for adherence to the antibiotic stewardship program to track and manage infections effectively.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct a performance review for two certified nurse aides (CNAs) within the required 12-month period, as mandated by regulations. CNA #1, hired on February 28, 2023, and CNA #2, hired on November 29, 2022, did not have documented performance reviews completed within the past year. This deficiency was identified through record reviews and staff interviews. The human resources director confirmed that each department lead was responsible for conducting annual performance reviews, but acknowledged that reviews for CNA #1 and CNA #2 were not completed. The regional nurse consultant also confirmed the absence of performance reviews for these CNAs.
Failure to Honor Resident Preferences in Care and Scheduling
Penalty
Summary
The facility failed to honor the residents' rights to make choices about aspects of their lives, specifically for two residents. Resident #7, who was cognitively intact and had multiple medical conditions including a sacral pressure ulcer, was not provided assistance in scheduling a wound care appointment at his preferred in-network clinic. Instead, the facility arranged for him to attend an out-of-network clinic, resulting in a significant financial burden. The resident and his representative were not informed about the network status or financial implications of the clinic chosen by the facility. Despite the resident's request to attend an in-network clinic closer to the facility, the facility scheduled an appointment at a distant location, causing additional discomfort due to the long travel. Resident #2, who was also cognitively intact and diagnosed with Parkinson's disease, expressed a preference for three showers per week. However, the facility assigned shower days based on room numbers without consulting the resident's preferences. There was no documentation in the resident's electronic medical record or the shower binder to indicate the resident's shower preferences, and the staff followed a predetermined schedule without accommodating individual requests. Interviews with staff, including the wound care nurse and the regional nurse consultant, revealed a lack of communication and documentation regarding the residents' preferences and the financial aspects of care. The facility's policy on residents' rights was not adhered to, as staff failed to facilitate and support the residents' choices, leading to dissatisfaction and potential financial strain for the residents involved.
Failure to Revise Care Plan for Resident's Medication Refusals
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised in a timely manner to include necessary instructions for effective and personalized care. The resident, who had severe cognitive impairments and multiple diagnoses including Huntington's disease, dementia, and depression, frequently refused physician-ordered medications and treatments. Despite these refusals, the care plans did not document or address the resident's pattern of refusals, nor did they include person-centered interventions to manage these refusals. The resident's medication administration record revealed multiple instances where medications such as Aspercreme and Haloperidol were not administered due to the resident's refusal. Additionally, the treatment administration record showed that the resident often refused to be moved to her chair for meals, as requested by her family. There was no documentation in the resident's electronic medical record indicating that the facility attempted to address these repeated refusals or update the care plan accordingly. Interviews with facility staff, including an LPN, a primary care provider, and a regional nurse consultant, confirmed that the resident's refusals were known but not adequately addressed. The LPN and RNC acknowledged the resident's right to refuse care but emphasized the need for re-approaching the resident and seeking assistance from other nurses. However, the care plan did not reflect these strategies or any person-centered interventions to reduce the number of refusals, leading to a deficiency in the resident's care management.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary services to maintain personal hygiene. The resident, who was under 65 years old and had multiple diagnoses including multiple sclerosis and severe cognitive impairments, was dependent on staff for showering and dressing. Despite the resident's preference for morning baths, as documented in her care plan, she reported not receiving a shower since her admission to the facility. Observations and interviews revealed that the resident's hair was greasy and her fingernails were unkempt, indicating a lack of personal hygiene care. The facility's records showed no documentation of the resident being offered a shower since her admission. A grievance was filed by the resident, but there was no documentation of any follow-up action to offer her a shower after the grievance was filed. Interviews with staff, including an LPN and a CNA, indicated that showers were scheduled based on room numbers rather than resident preferences. The staff were unaware if the resident had received a shower since her admission. The regional nurse consultant acknowledged the grievance and stated that the resident should have been offered a shower within 24 to 48 hours of admission, highlighting a failure in the facility's process to ensure timely and appropriate personal hygiene care for the resident.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for its staff, specifically for two certified nurse aides (CNAs). The deficiency was identified through record reviews and staff interviews, revealing that the facility did not ensure that these CNAs received necessary training in areas such as abuse, dementia management, behavioral health management, infection control, communication, quality assurance and quality improvement (QAPI), compliance and ethics, and resident rights. Additionally, the facility did not provide documentation to confirm that these CNAs completed at least 12 hours of annual in-service training as required. Interviews with the human resources director (HRD) and the regional nurse consultant (RNC) further highlighted the issue. The HRD admitted that while training was supposed to be completed through an electronic learning management program, there was no documentation to prove that the CNAs had completed the required training in the past 12 months. The HRD also mentioned an annual skills clinic training and monthly staff meetings that included training, but again, there was no documentation to confirm attendance by the CNAs. The RNC acknowledged the difficulty in ensuring staff completed the required annual training, confirming that the CNAs did not complete the necessary training in the past year.
Latest citations in Colorado
Two severely cognitively impaired residents in a memory care unit, both with dementia and significant behavioral risk factors, became agitated with each other and engaged in a physical altercation that resulted in a facial scratch to one resident. Facility policy required immediate intervention, separation, and monitoring to prevent abuse, and both residents’ care plans identified risks for aggression, anxiety, and resident-to-resident altercations. Staff reported that only one staff member was assigned to seven residents, that residents often invaded each other’s space, and that fights did occur, including a fist fight between these two residents during the incident in question. The facility’s investigation substantiated the event as physical abuse, demonstrating a failure to protect residents from abuse and to implement effective monitoring and behavioral interventions.
A resident with bipolar disorder, PTSD, traumatic brain injury, and moderate cognitive impairment alleged that an LPN and CNA were rough and sexually abusive during incontinence care, stating the LPN aggressively rolled him, caused his head to hit the wall, and repeatedly inserted a finger into his anus despite his protests. The facility’s investigation relied on staff statements and lack of observed rectal trauma, did not interview the roommate, and did not explore why staff continued care after the resident’s abuse allegation. The resident also reported ongoing rough transfers, inadequate repositioning in a wheelchair causing pain and bruising, and lack of assistance with proper positioning for meals, which was corroborated by observation of poor positioning, a bruise on his arm, and food spilled on his shirt. Although the care plan noted a history of false allegations and required care in pairs and investigation of voiced concerns, it lacked a specific focus on the resident’s PTSD and did not address his repeated reports that staff’s incontinence care and handling were rough and abusive.
A resident with a history of falls, fractures, and significant mobility impairment experienced an unwitnessed fall from bed, which had been left in a high position despite care-plan interventions requiring it to be kept low with a fall mat. An RN found the resident on the floor, initiated neuro checks, and documented elevated BP readings and pain but did not complete or document a thorough head-to-toe assessment before moving the resident back to bed, and did not promptly notify the MD, hospice, or the resident’s representative. Hospice was contacted several hours later due to rising BP and severe pain; a hospice RN then assessed the resident, notified the on-call MD, and obtained an order to transfer the resident to the hospital, where imaging revealed multiple fractures and a scalp contusion. Staff interviews and facility policy confirmed that standard practice required immediate RN assessment prior to moving a fallen resident, timely MD and family notification, and adherence to fall-prevention interventions, all of which were not followed in this case.
The deficiency centers on failures in transportation safety and fall management that led to serious resident injuries. A resident with dementia and bilateral lower extremity impairments was transported in a wheelchair without foot pedals, seated on a blanket and Hoyer sling, and improperly restrained when the driver misapplied the lap and shoulder belt to avoid disturbing an ostomy bag. During the trip the resident slid forward, struck both legs on a step in the vehicle, and was later found to have bilateral tibial fractures with significant bruising, swelling, and pain. The driver’s training had been informal, passed down from another staff member without documented competencies, van‑specific procedures, or clear emergency protocols, and leadership acknowledged they had not investigated the admitted misuse of the seat belt. Separately, two residents at high risk for falls experienced multiple falls, including one with a facial laceration and maxillary sinus fracture, while care‑planned fall interventions such as scheduled toileting, prompted voiding, monitoring, and assisted transfers were not consistently implemented, and IDT reviews and implementation of recommended interventions were not always timely.
A resident with severe cognitive impairment, multiple comorbidities, and a known history of alcohol use left the facility and was later found outside yelling for help and lying on the ground. Police identified the individual, determined the resident was intoxicated, and returned him to the facility, where he required wheelchair transport to his room despite normally walking without assistive devices. Officers helped the resident into bed, but nursing staff did not complete a change of condition assessment, obtain vitals, perform a head-to-toe or post-fall evaluation, or document his condition or monitoring afterward. The physician and legal guardian were not notified of the intoxication or change in condition, and there was no care plan addressing alcohol use or intoxication despite existing orders to monitor for substance use and notify the provider. A few hours later, a CNA found the resident face down on the floor, unresponsive, and he was pronounced dead, with the death certificate citing respiratory failure, aspiration event, and alcoholism; the incident was not promptly reported or thoroughly investigated at the time.
A resident with cognitive impairment and documented visual deficits requested very hot tea, which a PTA dispensed from a hot beverage machine and then further heated in a microwave, contrary to facility policy prohibiting reheating of facility-provided drinks. The PTA secured a lid on the cup and placed it at the bedside. Due to visual impairment, the resident could not locate the drinking opening, attempted to remove the lid independently, and spilled the hot liquid onto an arm and thigh, sustaining second-degree partial thickness burns over approximately 6% TBSA. Nursing and NP assessments documented bright red, blanchable burns with blistering and subsequent healing, and staff interviews confirmed that the beverage had been overheated and that the resident’s visual impairment and lack of appropriate supervision and adaptive equipment contributed to the accident.
A resident with CHF and multiple comorbidities was readmitted from the hospital with an order for metolazone 2.5 mg PRN, to be given only when weight increased by 5 lbs over baseline and 30 minutes before Lasix. Due to incorrect transcription of the hospital discharge orders into the EMR by the ADON, and the absence of a required second-nurse verification, metolazone was entered and administered as a scheduled daily medication instead of PRN. Nursing staff gave the drug daily for eight days without confirming the weight-based parameter, including on days when no weight was obtained and when the resident’s weight was stable or decreasing. During this period, the resident experienced a 12–14 lb weight loss, marked weakness, fatigue, excessive somnolence, and was later found to have hypokalemia, while continuing on other diuretics (Lasix and spironolactone). Interviews with the resident, her representative, nursing staff, the DON, PCP, and pharmacist linked these changes to the medication error, which did not follow the prescriber’s PRN order or the facility’s medication error policy.
The facility failed to maintain a full-time RN DON when the existing DON was reassigned as a temporary emergency NHA, leaving no separate RN designated to the DON role. Records showed the acting NHA held a temporary administrator permit while the staffing list indicated no full-time DON in place, despite a job description assigning the DON responsibility for 24-hour nursing oversight, staffing, and key clinical systems. Staff interviews revealed that nurses were unaware of the DON’s reassignment and continued to view this person as their direct supervisor, while the acting NHA reported performing both administrative and DON functions, including abuse coordination and state occurrence reporting, without any formal announcement or signage to inform staff, residents, or families of these role changes.
The facility’s QAPI program failed to identify and address critical quality of care issues related to resident change in condition, despite a written policy requiring comprehensive, data‑driven performance monitoring and corrective action. The facility had repeat F684 citations for quality of care and, in the current survey, was found to have not adequately assessed, monitored, documented, or communicated a resident’s change in condition, which was associated with the resident’s death and resulted in an immediate jeopardy finding. The MD reported he reviewed only those cases and policies presented to him and was unaware that the DON was also serving as the temporary emergency NHA amid leadership changes. The DON/acting NHA stated that QAPI meetings focused on standard topics and that change of condition evaluations were limited mainly to skin alterations and falls, acknowledging that staff were new to other types of change of condition assessments requiring thorough evaluation and provider/family notification.
A resident with CVA-related left-sided hemiplegia, who used a wheelchair and was cognitively intact, was moved to a different room after reporting strong chemical odors and refusing to return to the original room. Facility policy stated that staff would assist with packing and unpacking belongings for room changes, and staff reported that environmental services, nursing, or maintenance typically helped move items. In this case, however, staff repeatedly told the resident they could not move her belongings and would only escort her while she attempted to move them herself, despite her physical limitations. The NHA communicated by email that, due to prior disputes about handling of personal property, the resident was responsible for arranging family or third-party movers at her own expense, while staff would only provide access and oversight. As a result, most of the resident’s personal items remained in the original room for an extended period after she agreed to the permanent room change.
Failure to Prevent Resident-to-Resident Physical Abuse in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, specifically resident-to-resident physical abuse between two cognitively impaired residents in the memory care unit. Facility policy required that residents be free from all forms of abuse and that staff immediately intervene, ensure resident safety, and keep residents separated and monitored when an assailant is identified. Despite this policy, the facility’s own investigation of an incident on 11/26/25 documented that two residents in the memory care unit became frustrated and agitated with each other, with elevated voices and defensive body language, and moved their arms as if they were going to hit each other. One resident sustained a superficial scratch above his left eyebrow, and the investigation concluded that the other resident likely made contact, resulting in the injury, and the incident was substantiated as physical abuse. One resident involved had Alzheimer’s disease and schizophrenia, was severely cognitively impaired with a BIMS score of 1, and required maximum assistance with ADLs. His care plan identified him as being at risk for resident-to-resident altercations related to individuals invading his space and at risk for re‑traumatization, with anxiety triggered by male caregivers or those perceived to be male. Interventions in his care plan included providing opportunities for positive interaction and attention, such as stopping and talking with him while passing by. On the date of the incident, a skin assessment documented a scratch above his left eyebrow, consistent with the facility’s determination that he was the victim of physical abuse by another resident. The other resident involved had Lewy body dementia, hypertension, and depression, was also severely cognitively impaired with a BIMS score of 0, and required maximum assistance with ADLs. His behavior care plan identified a risk for verbally abusive behaviors and potential psychosocial issues due to a prior incident in which he had received unprovoked agitation with physical abuse from another resident, with interventions including monitoring for signs of aggression, fear, or psychosocial trauma and documenting behaviors and interventions. An antipsychotic medication care plan further identified him as being at risk for aggressive behaviors, including non‑redirectable agitation, with instructions to intervene immediately if agitation was observed. Staff interviews indicated that only one staff member was assigned to seven residents on the unit, that residents sometimes got into each other’s space and fights occurred, and that the two residents had been seen in a fist fight on the date of the incident, demonstrating that the facility did not effectively prevent or intervene to stop resident‑to‑resident physical abuse in accordance with its abuse prevention policy and the residents’ care plans.
Failure to Thoroughly Investigate and Address Allegations of Sexual and Rough, Abusive Care
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document allegations of sexual abuse and rough, abusive care toward a resident. The facility’s abuse policy required that all reports of resident abuse be thoroughly investigated and documented. An investigation dated 2/24/26 addressed an allegation that a resident was sexually abused during incontinence care, but the investigation did not include interviewing the resident’s roommate about what he might have seen or heard during the alleged incident. The investigation concluded the allegation was unsubstantiated based on lack of physical trauma and staff statements, and it attributed the resident’s report to cognitive decline and terminal agitation, despite the resident’s clear and consistent account during the survey interview. The resident involved was under age 65 with diagnoses including bipolar disorder, anxiety, depression, PTSD, and traumatic brain injury. A recent MDS showed moderate cognitive impairment (BIMS 12/15), aggressive behavior, and delusions, and the resident was dependent on staff for toileting, transfers, and bed mobility, using a manual wheelchair. During the facility’s investigation, the resident reported that while yelling for help after a bowel movement, a CNA entered and began care, and then an LPN took over. The resident stated he did not want the LPN to provide care, tried to swat him away, and that the LPN grabbed his hands, rolled him aggressively causing his head to hit the wall, and inserted a finger into his anus four times while wiping, despite the resident yelling for him to stop. Staff statements conflicted with the resident’s account regarding who provided care and what occurred, and the facility did not investigate why staff did not stop care and have another staff member take over when the resident alleged abuse during the episode. The resident continued to report that staff were rough and that their approach to care felt abusive, including prior rough transfers by the same LPN and improper positioning and repositioning by other staff that caused pain and bruising. On the survey date, the resident described ongoing rough care, lack of staff responsiveness to his requests, and feeling that no one listened to or believed him. He reported that staff did not assist him to sit up properly for breakfast, resulting in difficulty eating and spilled food on his shirt. Observation during the interview showed the resident slouched and slumped to the left in his wheelchair, with his left arm hanging over the side, a bruise on his upper arm where the armrest was pressing, and dried oatmeal on his shirt from the morning meal. The resident’s care plan documented a history of false allegations and required care in pairs, investigation of all concerns voiced, and a calm, slow approach, but there was no specific care plan focus addressing his PTSD or his allegations of rough or abusive incontinence care, and the facility did not pursue his ongoing reports of rough and abusive treatment during personal care.
Failure to Assess, Notify, and Respond Appropriately After Unwitnessed Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards following an unwitnessed fall. A cognitively intact resident with a history of falls, prior fractures (including a right humerus fracture), osteoarthritis, muscle weakness, and difficulty walking was admitted with orders and care plan interventions that included keeping the bed in the lowest position, use of a high-impact fall mat, and a lipped mattress. The resident required maximal assistance with transfers and used a wheelchair. On the night of the incident, the resident was found on the floor on her left side in a somewhat fetal position, partially on and partially off the fall mat, with the bed raised in a high position. RN #1, who heard a loud sound and discovered the resident on the floor, documented an initial assessment that included vital signs showing elevated blood pressure and initiation of neurological monitoring. However, there was no documentation that RN #1 completed a thorough head-to-toe assessment before the resident was moved back to bed, despite facility policy requiring a nurse evaluation to determine presence of injury prior to moving a resident who has fallen. The record lacked evidence of a full assessment of injuries at the time of the fall, even though the resident later was found to have multiple fractures and a scalp contusion. Staff interviews, including from the DON and other nurses, confirmed that standard practice and policy required a complete RN assessment before moving a resident after a fall. Following the fall, RN #1 did not notify the physician, the resident’s representative, or hospice at the time of the incident, despite facility policy and staff statements that the physician and responsible party should be notified immediately after the assessment. The resident’s blood pressure continued to rise over several hours, and she complained of pain, yet the first notification was to hospice at 6:00 a.m., approximately three hours after the fall. The hospice RN arrived around 6:30 a.m., found the resident arousable to verbal stimuli with tense features, facial grimacing, and reporting severe pain, and then notified the on-call physician, who ordered transfer to the hospital. Hospital imaging revealed a left parietotemporal scalp contusion, an acute nondisplaced C7 vertebral fracture, multiple displaced fractures of at least the first six left ribs, a left scapula fracture, and a left clavicle fracture. The facility also failed to ensure the resident’s bed was maintained at a safe, low height as care-planned, and the transfer to the hospital did not occur until after hospice assessment and physician notification several hours post-fall. The resident’s representative reported that the resident lay in bed for three hours in severe pain without medical attention and that the family and physician were not notified by facility staff, but rather by hospice. Documentation showed that the facility did not contact the resident’s representative until later that afternoon, after the hospital had already identified multiple fractures and the resident was being admitted to intensive or trauma care. Staff interviews, including from CNAs, an LPN, an RN, and the DON, consistently described that facility practice required immediate RN assessment before moving a resident, prompt vital signs and neurological checks, and immediate notification of the physician and responsible party after a fall, particularly if there was pain or potential major injury. In this case, the facility failed to accurately and timely assess the resident after the fall, failed to promptly notify the physician and responsible party, did not ensure the bed was at the lowest and safest height, and did not ensure timely transfer to the hospital after an unwitnessed fall that resulted in major injury and pain. The facility’s own fall care plan and incident policy emphasized prevention of avoidable accidents, completion of a nurse evaluation prior to moving a resident who has fallen, and documentation of injury status and notifications. Despite these requirements, the EMR lacked a full head-to-toe assessment at the time of the fall, and the DON acknowledged that RN #1, an agency nurse, failed to document the fall appropriately, complete an accurate assessment, and notify the physician and the resident’s representative. The hospice RN confirmed that RN #1 did not notify the physician or the resident’s representative and that hospice was contacted due to the resident’s increased pain and rising blood pressure. These actions and omissions collectively led to the cited deficiency for failure to provide treatment and care in accordance with professional standards and the resident’s care plan following the fall.
Transportation Safety and Fall Management Failures Leading to Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision to prevent accidents, particularly in relation to transportation safety and fall prevention. One resident with vascular dementia, bilateral lower extremity impairments, and dependence on staff for transfers was transported to an outside appointment in a facility vehicle while seated in a wheelchair without foot pedals. During the trip, the resident began sliding forward in the wheelchair. The transportation driver reported he could not immediately pull over while exiting the highway, and by the time he stopped, the resident had slid further forward so that her knees and legs were resting on a step behind the driver’s seat. The resident subsequently exhibited multiple bruises, abrasions, swelling of both legs, and severe pain. Facility records and later hospital documentation identified bilateral tibial fractures associated with this transport incident. The report details that the wheelchair was secured with a four‑point tie‑down, but the resident’s body was not properly restrained. The driver later demonstrated that he had routed the shoulder portion of the seat belt around the back of the van seat instead of across the resident’s shoulders, and placed the lap portion across the resident’s chest instead of her lap. He acknowledged this was not the proper use of the seat belt and attributed his actions in part to concern about disturbing the resident’s ostomy bag. He also stated that the resident was sitting on a blanket and a Hoyer sling, which he believed contributed to sliding, and that the absence of foot pedals left nothing to stop the resident’s forward movement. The facility’s own transportation policy required that drivers and passengers wear seatbelts and shoulder harnesses any time the vehicle was in motion and that wheelchairs be made secure with straps, but there was no evidence that the seat belt system was applied as intended in this case. The report further identifies systemic issues in transportation training and oversight that contributed to the deficiency. The van driver had been in the role for a little over a month and was trained informally by the central supply coordinator, who herself had been trained years earlier by a prior driver without documented competencies, checklists, or reference to an operations manual. The central supply coordinator reported no additional training or competencies since that initial instruction and was unaware of any policy or procedure for driving emergencies or clear guidance on whom the driver should contact for clinical or mechanical emergencies during transport. The maintenance director, responsible for monthly checks of the van, used a generic medical transport checklist, had no van‑specific training or competencies, and was unsure whether an operations manual was available. The administrator acknowledged that she was not sure what competencies the trainer had when she trained the current driver, that the DON and ADON were not trained on transportation, and that no investigation was completed into the driver’s admitted misuse of the seat belt. Collectively, these actions and inactions led to the transportation‑related accident and constituted a failure to maintain an accident‑free environment and adequate supervision. In addition, the deficiency includes failures related to fall management for two other residents at high risk for falls. One resident with vascular dementia, muscle wasting, difficulty walking, and severe cognitive impairment experienced 16 falls over a defined period, including an unwitnessed fall that resulted in a facial laceration and a maxillary sinus fracture requiring emergency department evaluation. The facility had a fall management policy requiring IDT review of falls and individualized care plan interventions, and the resident’s care plan contained multiple fall interventions such as scheduled toileting, prompted voiding, use of a non‑recording video monitor, and assistance with transfers. However, the report notes that care‑planned fall interventions were not consistently implemented in a timely manner, and surveyor observations during the survey period showed that staff were not consistently following the resident’s fall interventions. The report also notes that the IDT did not consistently review falls in a timely manner or ensure that recommended interventions were implemented. For the high‑risk resident with multiple falls, IDT notes documented repeated unwitnessed and witnessed falls associated with poor safety awareness, failure to use the call light, weakness, and attempts to ambulate or transfer without assistance. New interventions such as occupational therapy evaluations, room relocation closer to staff, and pharmacy review were recommended, but one occupational therapy evaluation was recommended after a fall even though it had already been recommended after a prior fall, indicating delays or gaps in implementation. Another resident with multiple falls had no timely identification and documentation of fall interventions after several falls. These patterns demonstrate that the facility did not ensure timely IDT review of falls or consistent implementation of care‑planned fall interventions, contributing to repeated falls and at least one major injury. Overall, the cited deficiency encompasses the facility’s failure to safely transport a dependent, cognitively impaired resident in accordance with its own transportation safety policy, resulting in bilateral tibial fractures, and its failure to consistently implement and timely review fall prevention interventions for residents at high risk for falls, including residents who sustained multiple falls and a serious injury.
Removal Plan
- Temporarily suspend all facility resident transportation services and transfer transportation to an outside company pending completion of training and validation.
- Immediately remove all staff members assigned transportation responsibilities from transportation duties pending completion of retraining and competency validation.
- Transport residents requiring appointments using medical transportation services through external transportation companies.
- Implement a resident transportation risk assessment tool to identify residents who require special transportation precautions; assess all residents who utilize facility transportation using this tool.
- Implement a comprehensive transportation safety program including: updated Transportation Safety Policy; Transportation Driver Job Description with defined safety duties; Transportation Staff Competency Validation process; Pre-Transport Safety Checklist (reviewed by administrator or designee); Transportation Special Circumstances Protocol; Transportation Incident Investigation Template; Transportation Safety Training Program; and Transportation Safety QAPI Monitoring Process.
- Require wheelchairs to be secured using a four-point tie-down system.
- Require residents to be secured with lap and shoulder seatbelts.
- Verify wheelchair brakes and foot pedals prior to transport by the administrator or designee.
- Confirm resident stability before departure by the administrator or designee.
- Evaluate residents’ medical devices/special medical circumstances individually (e.g., ostomies, indwelling urinary catheters, suprapubic catheters, oxygen equipment, other devices) and implement appropriate precautions prior to transportation as necessary.
- Provide mandatory transportation safety training for all transportation staff (wheelchair securement, restraint placement, medical device accommodations, emergency response); document attendance and validate competency using a checklist, with validation by the maintenance director and clinical liaison/designee as approved by the administrator.
- Complete a Pre-Transport Safety Checklist prior to each transport verifying wheelchair brakes engaged, foot pedals attached, four-point tie-down secured, lap and shoulder restraints applied, medical devices protected, and resident stability confirmed (completed by Maintenance Director and Clinical Liaison/Designee).
- Use a transportation incident ad hoc QAPI tool to ensure structured review of any transportation-related incident (incident description, equipment review, root cause analysis, corrective action planning).
Failure to Assess and Respond to Resident Intoxication and Change in Condition Resulting in Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with multiple complex medical conditions received treatment and care in accordance with professional standards of practice following a clear change in condition related to alcohol intoxication. The resident had diagnoses including alcoholic polyneuropathy, history of traumatic brain injury, CHF, type 2 diabetes mellitus, alcoholic cirrhosis of the liver, hypertension, long-term anticoagulant use, and alcohol use with an unspecified alcohol-induced disorder. His MDS showed severe cognitive impairment and functional dependence for many ADLs, though he typically ambulated without a mobility device. Physician orders included monitoring for potential substance use each shift and documenting and notifying the physician if any substance use indicators were noted, but the January TAR documented no substance use behaviors for that month. On the day of the incident, the resident signed out of the facility in the morning and was later found outside the facility grounds by bystanders, yelling for help and lying on the ground near a hotel with a shopping cart. Police dispatch records show multiple calls reporting the resident on the ground and yelling for help, and the police ultimately identified him and returned him to the facility. The police reported to staff that the resident was intoxicated and had been wandering. Upon return, he required wheelchair transport from the front door to his room, despite normally walking without assistive devices. According to an IDT note, officers assisted him in removing his shoes and coat and helped him into bed, after which he was observed resting in his room, but no time or assessment details were documented. Record review revealed no documentation that nursing staff completed a change of condition assessment, a post-fall or post-ground-level event assessment, or any RN assessment when the resident was returned by police in an intoxicated state. There was no documentation of vital signs, head-to-toe assessment, skin evaluation, or monitoring between the time of his return and the time he was later found unresponsive. The physician and the resident’s legal guardian were not notified of his intoxication or change in condition, and there was no progress note describing his condition upon return or how he was transferred to bed. The resident’s comprehensive care plan contained no care plan addressing alcohol use, intoxication, or potential substance use, and there were no interventions related to his known history of alcohol abuse and drinking while away from the facility. Staff interviews, including with the DON/acting NHA, ADON, and RNs, confirmed that no change of condition assessment, vital signs, or physician/guardian notifications were completed despite their own descriptions of what should occur when a resident returns intoxicated. The resident was later found face down on the floor in his room, unresponsive, and was pronounced dead; his death certificate listed respiratory failure, aspiration event, and alcoholism as the causes of death. The facility also failed to promptly recognize and investigate the incident as an unexpected death associated with a significant change in condition. A frequent visitor reported that the DON/acting NHA initially did not believe an occurrence report was required for the resident’s intoxicated return and unexpected death, and the occurrence report to the state was not submitted until eight days after the death. There was no evidence of an immediate, thorough internal investigation or root cause analysis at the time of the event to determine why nurses did not complete a change in condition assessment or follow the existing physician order to monitor for substance use and notify the physician. Surveyors determined that the facility did not thoroughly assess and monitor the resident’s alcohol use and change in condition, did not document changes, and did not seek medical treatment or notify the physician and guardian when required, and that these failures contributed to serious harm and death for the resident.
Removal Plan
- NHA notified the facility medical director of the incident.
- Nursing supervisors/designees completed physical assessments/interviews on all residents to identify any changes in condition and notified the physician of any noted changes.
- Initiated a look-back audit of current and discharged residents to ensure change-of-condition policy was followed.
- Identified one current resident without a required 72-hour alert monitoring order; educated the assigned nurse regarding timely initiation of the 72-hour alert monitoring order after completing the eINTERACT change-in-condition evaluation.
- Initiated the missing 72-hour change-in-condition alert monitoring order for the identified resident, including nursing assessments and documentation on the TAR and in progress notes each shift for three days per physician-indicated frequency.
- Reviewed resident change-in-condition and notification policies/procedures for clinical accuracy.
- Educated all nursing staff on addressing changes of condition (assessment, monitoring, physician/family notification, orders, and facility policies/procedures); staff were not permitted to work a shift until education was completed.
- Educated new hires (licensed nurses and nurse aides) during orientation on change-of-condition and physician/family notification requirements and facility policies/procedures.
- DON/designee to conduct audits five times per week for three months of the 24-hour report and progress note report to ensure change-of-condition policies/procedures are followed.
- DON/designee to conduct daily nursing staff huddles Monday through Friday to monitor for changes in resident condition.
- Regional director of clinical services and regional vice president to provide clinical/administrative oversight to ensure education and audits are completed and accurate.
- DON educated by the CNO on appropriately addressing changes of condition (assessment, monitoring, physician orders, and facility policies/procedures).
- DON/designee to complete chart audits to verify detailed assessments/documentation and physician/family notification related to changes of condition.
- Regional Director of Clinical Services to visit the facility to provide general oversight and monitoring of the plan.
Burn Injury from Improperly Heated Hot Beverage and Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from accident hazards and received adequate supervision when provided a hot beverage. A resident with diagnoses including a displaced intertrochanteric fracture of the left femur with routine healing, unspecified cataract, unspecified macular degeneration, disorientation, and restlessness and agitation requested very hot tea. The resident had moderate cognitive impairment with a BIMS score of 11 and was care planned as needing set-up assistance with eating and drinking. Although an MDS assessment indicated adequate vision without corrective lenses, subsequent care planning documented vision impairment related to cataracts, macular degeneration, and diplopia, and that the resident wore an eye patch and glasses. On the day of the incident, the resident asked a physical therapy assistant (PTA) to make her tea “very hot.” The PTA dispensed hot water for tea from the kitchenette coffee machine and then heated the beverage in a microwave for an additional 30 seconds at the resident’s request. The PTA then secured a lid on the cup and placed it on the resident’s bedside table. The facility’s Hot Beverage policy, in effect at the time, stated that hot beverages were to be served at a safe, palatable temperature, that hot beverage machines were to be set and maintained at manufacturer-recommended temperatures, and that microwaves were not to be used to reheat hot beverages if the temperature was not considered palatable; instead, a fresh cup was to be poured. The policy also directed staff to report safety or decline in managing hot beverages to the IDT or therapy for review and possible care plan updates. After the PTA placed the lidded cup at the bedside, the visually impaired resident attempted to drink the tea but could not locate the opening in the lid due to her macular degeneration. The resident then attempted to remove the lid independently, during which the hot tea spilled onto her right forearm and right posterior thigh. Nursing assessment documented bright red, blanchable burns with a broken blister on the arm, and measurements of 8 cm by 5 cm on the arm and 12 cm by 22 cm on the thigh. The NP assessed the injuries as second-degree partial thickness burns involving approximately 6% total body surface area, with the resident reporting pain of 3 out of 10 and denying numbness, tingling, fevers, or chills. Subsequent documentation showed the wounds progressing with scabbing and epithelial tissue formation prior to the resident’s discharge home. Staff interviews confirmed that, following the incident, it was recognized that the tea had been heated beyond the temperature at which it was dispensed from the coffee machine and that the resident’s impaired vision contributed to her difficulty using the standard lidded cup. The DON and RN stated that the PTA had reheated the tea in the microwave without checking the temperature and then served it to the resident, contrary to the facility’s policy prohibiting reheating of facility-provided drinks in microwaves. The dietary manager and nursing staff also indicated that the facility’s practice was to avoid reheating hot beverages and to rely on the coffee machine settings, which were kept at or below 160°F, rather than using microwaves for additional heating. These actions and inactions led to the resident being provided an excessively hot beverage in a manner that did not account for her visual impairment, resulting in the burn injury. The facility’s failure centered on not adhering to its own Hot Beverage policy and not adequately supervising or accommodating the resident’s known visual impairment when providing a very hot beverage. The PTA’s use of the microwave to further heat the tea, the absence of a temperature check before serving, and the placement of a standard lid that the visually impaired resident could not safely manage independently all contributed to the incident. The care plan at the time identified the resident as needing set-up assistance and, after the incident, was updated to include interventions such as encouraging the resident to leave lids on hot beverages and to use the call light for assistance with lids, indicating that these precautions were not in place or not implemented at the time of the burn event.
Failure to Follow PRN Diuretic Order Leads to Significant Weight Loss and Hypokalemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a diuretic, metolazone, was entered and administered as a scheduled daily medication instead of as a PRN medication with specific weight-based parameters. After an acute hospitalization for conditions including acute on chronic CHF, acute respiratory failure with hypoxia, COPD, atrial fibrillation, hypertension, morbid obesity, COVID-19, and MDRO history, the resident was readmitted to the facility. The hospital discharge order specified metolazone 2.5 mg to be taken once daily as needed for pulmonary edema due to chronic heart failure, only when the resident had a weight gain of 5 lbs over baseline, and to be given 30 minutes prior to Lasix. However, when the orders were transcribed into the facility’s EMR on readmission, metolazone was entered as a scheduled daily medication without PRN parameters, and this incorrect order did not match the hospital discharge instructions. The assistant DON, who entered the readmission orders from the hard-copy discharge packet because the phone lines were down and the usual electronic admission process was not used, input metolazone as a daily scheduled medication. The normal process of having two nurses verify and enter orders was not completed; the ADON entered the orders alone, and the second nurse verification did not occur. As a result, nursing staff administered metolazone 2.5 mg daily for eight days, in addition to the resident’s other diuretics (Lasix and spironolactone), without confirming that the resident had experienced the required 5 lb weight gain from baseline. The MAR documented daily administration of metolazone over this period, including on days when no weight was obtained, and on days when the resident’s weight was stable or decreasing rather than increasing. During this time, the resident experienced significant weight loss and symptoms consistent with a change in condition. Weight records showed a decline from approximately 190 lbs prior to hospitalization to 176.6 lbs when the error was identified, reflecting a loss of about 12–14 lbs over a short period. The resident and her representative reported that she became severely weak, excessively tired, and felt she could not regain her strength, with the representative describing the resident as very tired, exhausted, and feeling as though she could not “hang on any longer.” Clinical documentation noted significant weakness, excessive sleepiness during therapy, and that the resident was triggering for significant weight loss. Laboratory testing later showed hypokalemia, with a potassium level of 3.2 mEq/L. Interviews with nursing staff, the DON, the ADON, the PCP, the pharmacist, the resident, and the resident’s representative consistently attributed the resident’s weight loss, weakness, and low potassium at least in part to the erroneous daily administration of metolazone instead of PRN dosing based on weight gain. The facility’s own medication error policy defined a medication error as preparation or administration of medications not in accordance with the prescriber’s order, manufacturer’s specifications, or accepted professional standards, and defined a significant medication error as one that causes resident discomfort or jeopardizes health and safety. In this case, the metolazone order in the EMR did not reflect the prescriber’s PRN order with weight-based parameters, and the medication was administered without verifying the required 5 lb weight gain. The resident’s care plan for diuretic therapy called for administering diuretics as ordered, monitoring for side effects such as fatigue and increased fall risk, and reporting pertinent lab results, including potassium. Staff interviews acknowledged that the error persisted for about eight days, that medication reconciliation was not completed upon readmission, and that the lack of a second nurse verification contributed to the error. The pharmacist and PCP described the effects of metolazone, especially in combination with Lasix, as including electrolyte abnormalities, weight loss, and weakness, and characterized the error as moderate, with the potential to increase electrolyte depletion and require close monitoring.
Failure to Maintain a Full-Time RN Director of Nursing During Temporary NHA Appointment
Penalty
Summary
The deficiency involves the facility’s failure to designate a registered nurse (RN) to serve as the full-time director of nursing (DON) while the existing DON was reassigned to act as the temporary emergency licensed nursing home administrator (NHA). Record review showed that the acting NHA held an active temporary permit for emergency situations beginning on 12/30/25 and expiring on 3/30/26. A staffing list review revealed there was no full-time DON in the building during this period. The DON job description, signed by the DON, specified that the DON’s primary purpose was to plan, organize, develop, and direct nursing operations, ensure quality resident care on a 24-hour basis, oversee recruitment and hiring of licensed personnel, manage nursing schedules, monitor staffing levels, and oversee implementation of nursing service objectives, policies, and procedures, including key clinical systems such as infection prevention and control, psychotropic and controlled substance management, skin and weight systems, risk management, and hospice liaison. Staff interviews confirmed that the individual serving as the full-time temporary NHA was also functioning as the full-time DON, with no other person appointed to the DON role. The chief nursing officer stated that the temporary NHA was also acting as the full-time DON and reported not knowing there was a regulation preventing this. Nursing staff, including an LPN and an RN, reported they were unaware that the DON had been appointed as the temporary NHA and continued to view the DON as their supervisor. The acting NHA described performing both administrative and clinical leadership duties, including occurrence reporting to the state, serving as abuse coordinator and investigator, and leading stand-up meetings, while relying on two unit managers, an LPN assistant DON, and an infection preventionist to assist with clinical duties and audits. There had been no announcement to staff, residents, or families about the acting NHA appointment or her role as abuse coordinator, and there was no signage indicating this responsibility.
Failure of QAPI Program to Address Change in Condition Leading to Immediate Jeopardy
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective, comprehensive, data‑driven QAPI program that identified and addressed quality of care concerns, particularly related to changes in resident condition. The facility’s QAPI policy required ongoing tracking and measuring of performance, identification and prioritization of quality deficiencies, systematic analysis of underlying causes, and development and monitoring of corrective actions, with a focus on resident safety, health outcomes, and high‑risk or problem‑prone areas. Despite this written policy, the facility did not operate its QA program in a manner that prevented repeat deficiencies, as evidenced by prior citations at F684 (quality of care) in consecutive annual recertification surveys. Surveyors found that the QAPI committee failed to identify and address concerns related to quality of care by not ensuring that resident changes in condition were assessed, monitored, documented, and communicated when indicated. This failure rose to the level of immediate jeopardy and was associated with a serious adverse outcome resulting in a resident’s death. The cross‑referenced F684 citation states that the facility failed to provide quality care by not assessing, monitoring, documenting, and communicating a resident’s change in condition when indicated. The facility’s regulatory history showed that F684 had been cited twice previously at a D scope and severity, indicating a potential for more than minimal harm, isolated, without effective QA‑driven prevention of recurrence. Interviews further demonstrated gaps in the QAPI program’s functioning and oversight. The medical director reported he visited at least twice a month, reviewed cases and policies presented to him, and made changes based on what was brought forward in QAPI, but he was not informed that the DON was also serving as the full‑time temporary emergency licensed NHA for several months, and he described multiple leadership changes. The DON/acting NHA stated that QAPI meetings were held monthly and covered standard topics such as admissions, discharges, falls, staffing, abuse, infection control, and grievances, with use of audit tools and tracking spreadsheets. However, she acknowledged that while change of condition evaluations were being done for skin alterations and falls, staff were “new to the other types of change of condition assessments” that required thorough assessment and notification of the physician and family/guardian, and that change of condition evaluations beyond those limited areas had not been a focus of QAPI until after the incident that led to the immediate jeopardy finding.
Failure to Provide Timely Assistance With Resident Room-Change Belongings
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences during a room change, specifically by not providing timely assistance with moving the resident’s personal belongings. The facility’s Room Change policy, revised April 2025, states that environmental services staff or a designee will assist residents to pack their belongings prior to a room change, and nursing staff will assist residents to unpack belongings and get settled into the new room. The policy does not specify who will physically move the belongings between rooms, but staff interviews indicated an expectation that environmental services, nursing, or maintenance staff would typically assist with moving items or furniture. The resident involved was under age 65 and had multiple diagnoses, including CVA with left-sided hemiparesis and spastic hemiplegia, coronary artery disease, hyperlipidemia, depression, ADHD, lower back pain, and muscle weakness. The resident was cognitively intact with a BIMS score of 15, used a wheelchair for mobility, and was independent with hygiene, toileting, bathing, and dressing, but required setup and cleanup assistance with eating. The resident had documented verbal behavioral symptoms such as yelling and cursing, and a behavior care plan that included communicating via email and following up on concerns in a timely manner. The resident reported irritation of the nose and eyes and refused to return to her original room after complaining of a strong smell of ammonia and bleach, and staff assisted her into another room that night so she could sleep. Following this move, the resident requested assistance from staff to bring toiletries, a plant, and other personal items from the original room to the new room. Progress notes documented that staff told the resident they were not allowed to move her belongings and could only accompany her while she moved them herself, despite her left-sided hemiplegia and inability to move the items independently. The resident stated she was told she needed to move the items herself or arrange for someone else to move them and that she felt she should not have to pay to move her own items because the facility had offered the room change. Email communications show that the NHA characterized the room change as an accommodation requested by the resident and informed her that, due to prior concerns about staff handling her property, her belongings should be moved by family, an authorized representative, or a third-party mover at her own expense, with staff only providing access and oversight. The resident agreed to permanently move to the new room, but most of her belongings remained in the previous room, and staff continued to only escort her to retrieve items herself. Staff interviews confirmed that, in typical room changes, families or staff would assist with moving belongings, and that in this case the facility did not expect the resident to move her own items but also did not provide direct assistance or documented resources for moving services. The permanent move of the resident’s belongings did not occur until 39 days after she agreed to the room transfer, during which time the majority of her personal items remained in the original room.
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