Hale Nani Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Honolulu, Hawaii.
- Location
- 1677 Pensacola Street, Honolulu, Hawaii 96822
- CMS Provider Number
- 125011
- Inspections on file
- 26
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Hale Nani Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors observed multiple failures in infection prevention, including staff not performing hand hygiene between resident care tasks, improper doffing of PPE, and incorrect storage and changing of respiratory equipment. Additionally, required Covid-19 testing was not completed within policy timeframes for residents exposed to positive cases, and staff did not consistently use appropriate PPE when assisting residents on contact precautions.
The facility did not provide required written transfer or discharge notifications to two residents, their representatives, or the Ombudsman, and used forms missing the Ombudsman's address and appeal rights information. Staff were unaware of the notification requirements, and documentation was lacking for multiple hospitalizations.
Two residents with significant mobility limitations did not receive consistent range of motion (ROM) and splinting interventions as ordered in their care plans. Observations and record reviews showed that required ROM exercises and splint applications were missed on multiple occasions, and staff interviews confirmed that these services were not provided at the prescribed frequency due to staffing shortages.
Two residents were placed at increased risk of accidents due to inadequate supervision and unsafe environmental conditions. One resident with dementia and mobility issues was repeatedly observed wandering unsupervised, despite care plan interventions requiring close monitoring. Another resident who smokes was escorted to a designated smoking area that lacked a fire extinguisher and had improper disposal of cigarette butts, contrary to facility policy. Staff interviews confirmed awareness of these deficiencies.
Two residents experienced inadequate pain management due to staff failing to assess and monitor pain appropriately, including not pre-medicating a non-verbal resident before PROM exercises and not using effective communication tools for a resident whose preferred language was Vietnamese. Staff did not follow care plan interventions or use available pain assessment resources, resulting in unaddressed pain and discomfort.
Three residents and a representative did not understand the Binding Arbitration Agreement they signed during admission, as they either did not recall signing it or were unaware of its implications, despite facility policy requiring clear explanation and acknowledgment of understanding.
Staff failed to maintain resident dignity during mealtime assistance by standing over residents instead of sitting at eye level, leaving residents unattended, and engaging in unrelated conversations while assisting with meals. CNAs and an LPN confirmed awareness of proper procedures, and the DON stated that staff are expected to sit beside residents to promote comfort and communication.
Two residents with severe cognitive impairment were not supported in the care planning process by their representatives, as required. One resident's representative was not invited to participate in the care plan meeting, and for another, the required quarterly care planning meeting was missed, leaving the family representative uninvolved. Staff confirmed the lack of notification and documentation for representative participation.
A resident with moderate cognitive impairment was found with multiple medications left at her bedside for self-administration, despite no documented assessment confirming her ability to do so. Nursing staff acknowledged the error, and the DON confirmed that the resident was not clinically appropriate for self-administration and lacked the required assessment.
A resident who was fully dependent on staff and unable to bend her knees was not provided with a shower gurney, resulting in her receiving only bed baths despite her preference for weekly showers. Staff confirmed that no shower gurneys were available and that only one mechanical lift was present on the floor for nine residents who required it, with the lift sometimes being unavailable due to use on other floors.
A resident who was fully dependent on staff for personal hygiene expressed a preference for showers, which was communicated by her family and noted as important in her assessment. Despite this, staff were unaware of her preference, and she was only provided bed baths according to the posted schedule. The DON confirmed that the facility had not identified or documented the resident's bathing choice, and necessary equipment to support her preference was not secured.
Two residents who managed their own trust accounts did not receive required quarterly personal fund statements directly from the facility, despite being cognitively intact and designated as their own responsible persons. Statements were sent to off-site addresses or family members, and there was no documentation or tracking to confirm delivery to the residents, leaving them unaware of their account balances.
A documentation station used by CNAs and RNAs was left open and accessible in a busy hallway, displaying a resident's personal and clinical information. Staff interviews confirmed the station should have been closed to protect privacy and comply with HIPAA, in line with facility policy.
Two residents were found in unclean conditions, with one using dirty fall mats and another sitting beneath a stained ceiling tile. Staff were unaware of the issues and could not confirm when cleaning or maintenance had last occurred.
Two residents did not receive accurate assessments: one with severe cognitive impairment and a history of wandering was not coded for wandering behaviors despite repeated unsupervised ambulation, and another who speaks only Vietnamese was marked as rarely understood after a BIMS assessment was attempted in the wrong language, leading to unmet needs.
The facility did not develop or implement complete, individualized care plans for several residents, including one with incontinence and skin breakdown, another needing interpreter services, and a third requiring trauma-informed care. Staff were observed using improper peri-care techniques, and care plans did not reflect residents' specific communication or psychosocial needs, resulting in unmet needs and a decline in quality of life.
A resident with end stage renal disease returned from dialysis with a pressure dressing on the access site, but the facility did not revise the care plan to include interventions for care of the site or removal of the dressing. Nursing staff demonstrated inconsistent practices regarding responsibility and timing for removing the dressing, and the Director of Nursing confirmed there was no established protocol in place. This resulted in the resident retaining the pressure dressing for an extended period without appropriate assessment or intervention.
Two residents with limited English proficiency were not provided with effective communication supports, such as accessible communication boards or interpreter services, despite facility policy and care plans indicating these needs. Staff were unaware of available translation services and relied mainly on gestures, leaving residents unable to fully communicate their needs or express choices.
A resident returned from dialysis with a pressure dressing on their fistula, which was not removed for an extended period. The dressing was left on overnight and reapplied by the night shift due to bleeding, but was not reassessed or removed until late the next morning. The DON confirmed that the dressing should have been removed within a few hours and the site checked regularly, but this did not occur due to lack of communication and assessment.
A resident with a history of PTSD and other mental health diagnoses was not properly screened for trauma upon admission, and required assessments and checklists were either delayed or inadequately completed. Only the Social Services Director had completed trauma-informed care training, leaving other social services staff untrained at the time of the survey.
A resident with dementia and a history of stroke was repeatedly observed wandering unsupervised, taking food from others, and displaying aggressive behaviors. Staff and other residents reported ongoing distress, and interviews revealed that the underlying causes of the behaviors were not clearly identified or addressed in the care plan. Psychiatric referrals were delayed, and supervision was insufficient, resulting in continued behavioral issues affecting the unit.
A nurse administered scheduled medications, including antihypertensives with hold parameters, to a resident more than two hours early without verifying vital signs, and inaccurately documented the administration time. Additionally, a medication cart audit revealed incomplete narcotic count sheet documentation, with missing signatures and verification fields, contrary to facility policy.
A resident with multiple diagnoses did not have timely follow-up or proper documentation regarding pharmacist recommendations for medication changes, including a suggested GDR for Trazadone and monitoring after starting Lexapro. Required reviews and psychotropic meeting documentation were missing, indicating a lapse in the facility's medication management process.
Surveyors identified that medications were not properly stored, labeled, or administered according to professional standards. A resident was left unsupervised with medication, and staff failed to observe medication administration as required. Additionally, discontinued and unlabelled medications, including controlled substances, were found improperly stored in the medication cart, and not removed or disposed of per facility policy.
A resident with multiple chronic conditions was not provided with preferred food and drink options despite repeated requests and a diet waiver, resulting in the resident refusing facility meals and experiencing feelings of malnourishment and weakness. Staff interviews confirmed ongoing miscommunication between nursing and kitchen staff regarding the resident's dietary preferences.
Staff failed to consistently label and discard resident food items according to facility policy, with one container missing a date and another kept beyond the recommended three-day period. An RNA, LPN, and RN confirmed the improper storage, and a kitchen staff member clarified that nursing staff are responsible for labeling and discarding resident food. The facility lacked a policy specifying the maximum storage duration for these items.
A nurse administered multiple medications to a resident more than two hours before the scheduled time and documented them as given on time, contrary to facility policy and accepted nursing standards. The DON confirmed that medications should not be given or documented outside the one-hour window, and the documentation was found to be inaccurate and misleading.
Surveyors found that medication refrigerators and thermometers were not properly maintained, with one refrigerator freezer completely frozen and containing an unidentified frozen bag, and another refrigerator displaying a temperature above the recommended range while storing IV antibiotics, insulin, and immunizations. Staff attributed the temperature issue to overstocking and frequent access, and there was no set maintenance schedule for equipment checks, contrary to facility policy requiring regular monitoring.
Multiple incidents of resident-to-resident physical abuse occurred, including a cognitively impaired resident being assaulted by his roommate, altercations in hallways and common areas, and inadequate supervision during activities. The facility failed to document incidents properly, did not communicate effectively with residents or their families, and did not take immediate steps to prevent further abuse, despite known behavioral risks.
The facility did not employ a qualified full-time social worker as required for its size, with the Social Services Director and social services staff lacking the necessary educational credentials and relevant experience in health care settings.
The facility did not fully document or obtain all necessary witness statements during investigations of two separate resident-to-resident abuse incidents. In one case, a staff member present at the scene was not interviewed, and in another, the DON could not provide documentation of staff interviews and did not interview other residents present during the altercation.
A resident and their responsible party did not receive the required Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare-covered services. Instead, the NOMNC was sent on the same day services ended, contrary to facility policy and federal requirements. Staff interviews and record reviews confirmed the notice was not issued in a timely manner.
The facility did not report multiple incidents of resident-to-resident physical abuse to law enforcement, despite its policy requiring such reports for suspected crimes like assault. In each case, staff deferred to the wishes of the residents or their families, who declined police involvement, even though physical altercations occurred and were witnessed or documented. Leadership confirmed that law enforcement was not notified in these cases.
A resident with severe cognitive impairment and a language barrier did not receive required psychosocial follow-up after an allegation of physical abuse. Staff failed to conduct or document appropriate depression screening or psychosocial support, and did not use an interpreter or family assistance despite the resident's need for communication in Mandarin.
A resident's medical record contained conflicting documentation regarding the issuance date of a Notice of Medicare Non-Coverage (NOMNC). The responsible family member received the NOMNC via email on one date, while the EHR and social services note reflected an earlier issuance date. Staff confirmed the NOMNC was not issued on the date recorded in the documentation, resulting in inaccurate medical records.
A resident's grievance about neglect was not documented or investigated by the facility, violating her rights. The resident reported that a CNA and RN refused to change her incontinence brief, and the grievance was not logged as per the usual process. The Social Worker and Administrator confirmed the grievance was not documented, despite the facility's policy allowing oral or written submissions.
The facility did not follow its policy to screen potential employees for abuse history, as evidenced by the inability to provide a criminal background check for a CNA involved in a neglect allegation. A resident reported neglect by a CNA and an RN, and while the RN's background check was eventually provided, the CNA's remained outstanding, highlighting a lapse in the facility's screening procedures.
The facility failed to provide written transfer notifications to residents or their representatives before transferring them to an acute care hospital. This deficiency was identified for five residents, indicating a systemic issue with the facility's adherence to its own policy on admissions, transfers, and discharges. Interviews with the facility's social worker confirmed that the facility does not provide written notifications of transfer or discharge to residents or their representatives when they are sent to acute care.
The facility failed to provide written notification of the bed hold policy to residents or their representatives during transfers to hospitals or therapeutic leave. This affected five residents, as their electronic health records lacked documentation of such notifications. Interviews confirmed the facility's non-compliance with its policy, which requires providing this information before and during transfers.
The facility did not post daily nurse staffing data in accessible locations for residents and visitors. Observations showed missing or outdated postings on multiple units, and interviews revealed a lack of compliance with the facility's policy. The postings did not include unit-specific information, only facility-wide data.
The facility failed to conduct comprehensive care plan meetings with the required interdisciplinary team (IDT) members, including the attending physician and registered nurse, for several residents. Some residents were not invited to their care plan meetings, and outdated procedures restricted in-person attendance. The Director of Nursing confirmed the necessity of having all IDT members present, but this was not adhered to.
The facility failed to provide sufficient nursing staff, affecting residents' quality of life and well-being. Observations and interviews revealed inadequate staffing, particularly in RNA services, impacting residents' care. Resident council members reported consistent short-staffing, with fewer CNAs than required, affecting supervision and care routines. Record reviews showed higher resident-to-CNA ratios than recommended, leading to delays in care such as assistance, meals, and wound dressing changes.
The facility failed to ensure proper infection control practices, with staff not performing hand hygiene between glove changes or when moving between residents. A nurse did not wear a gown during a dressing change, and shared medical equipment was not sanitized after use. The DON confirmed these actions violated the facility's infection prevention policy.
The facility failed to treat residents with respect and dignity, as evidenced by long wait times for assistance, lack of communication, and inappropriate staff behavior. A resident reported waiting over 30 minutes for help after activating the call light, while another experienced confusion and distress due to a room change without her belongings. Additionally, a CNA was observed using personal electronic devices in residents' rooms, contrary to policy.
A facility failed to ensure a resident's representative, who was the DPOA for a resident with Alzheimer's, could exercise the resident's rights. The resident, with severe cognitive impairment, signed an informed consent for antidepressant use instead of the representative. The form lacked necessary details, and there was no documentation of verbal consent from the representative. Additionally, the representative was documented as attending a care plan meeting and declining services, but did not actually participate. Staff confirmed the resident's inability to make informed decisions, and the DON acknowledged documentation discrepancies.
The facility failed to honor the shower preferences of two residents, leading to a deficiency in accommodating their needs. A resident with multiple health conditions was observed wearing a soiled gown and reported receiving only monthly bed baths despite his care plan indicating he should receive showers twice a week. Another resident with ALS expressed frustration over not being allowed to shower despite requesting it multiple times. Staff interviews confirmed the lack of equipment to accommodate the resident's shower preference, leading to the deficiency in meeting the resident's needs as outlined in his care plan.
A resident did not receive quarterly statements of her personal funds, as they were sent to her sister in Texas instead. The resident, who is cognitively intact and responsible for her own finances, was unaware of her account balance. The facility's Business Office Manager confirmed the statements were not delivered to the resident, highlighting a deficiency in managing the resident's financial records.
The facility failed to provide a clean and homelike environment, as observed through peeling wallpaper, water-damaged ceilings, and malfunctioning toilets. A resident reported that the building's condition affected her well-being, while another was placed in a room with peeling paint. Despite maintenance efforts, a shared toilet continued to malfunction due to a bent handle and offset seal.
A resident was improperly restrained in a Geri-chair with a wheelchair wedged under the footrest, preventing her from adjusting the chair independently. This setup violated the facility's policy on physical restraints, which states that restraints should not be used unless required for medical treatment. The Nurse Manager confirmed that the use of the wheelchair in this manner was inappropriate, as the resident required supervision and medication adjustments, not physical restraints.
The facility failed to report allegations of abuse and injuries of unknown origin for two residents to the State Survey Agency (SA) and Adult Protective Services (APS). A resident with dementia was found with bruising on his hand, which was not reported as required. Previous injuries to the same resident were also not reported to APS. Another resident's abuse allegation was reported to the SA but not to APS, contrary to facility policy.
Infection Control and PPE Deficiencies Identified
Penalty
Summary
Multiple deficiencies in infection prevention and control were observed during the survey. Staff failed to perform proper hand hygiene between tasks, such as when a CNA assisted a resident with lunch, then handled used meal trays and other residents, and returned to feeding without sanitizing hands. The Director of Nursing confirmed that hand hygiene is required between tasks, and facility policy specifies hand hygiene before and after direct resident contact and when assisting with meals. Additional observations included staff not performing hand hygiene after doffing PPE and before accessing clean supplies, despite policy requirements for hand hygiene before and after entering transmission-based precaution areas and after handling food. Further deficiencies were noted in the management of medical equipment and infection control practices. A resident's catheter bag was found partially uncovered and in direct contact with the floor, rather than being properly hung from the bed frame. In another instance, respiratory care equipment, including a suction catheter, was not dated or stored correctly, and the tubing was not changed according to the facility's stated schedule. The Infection Preventionist confirmed these practices were not in line with facility policy, which requires suction catheters to be changed every 24 hours. The facility also failed to follow its own protocols for Covid-19 testing and use of personal protective equipment (PPE). Residents who were exposed to Covid-19 positive roommates were not tested within the required timeframes outlined in the facility's policy. Additionally, staff were observed assisting residents on contact precautions without wearing the required PPE, such as gowns, and some staff were unsure of the correct PPE to use. These lapses were confirmed by staff interviews and review of facility policies.
Failure to Provide Required Transfer/Discharge Notifications and Incomplete Notification Forms
Penalty
Summary
The facility failed to provide required written notifications of transfer or discharge to residents, their representatives, and the Office of the State Long-Term Care Ombudsman for two of three sampled residents. Specifically, for one resident who was transferred and discharged to the hospital on two occasions, there was no documentation of written notification to the resident, their representative, or the Ombudsman. The Director of Social Activities confirmed that written notifications were not provided and was unaware that such notifications were required. Additionally, the transfer/discharge notification form used by the facility did not include the Ombudsman's address as required by policy. For another resident with three hospitalizations, there was no discharge or transfer notification found for any of the hospitalizations. Although discharge notices were sent to the Ombudsman for two of the hospitalizations, there was no proof that notification was sent to the resident's representative. The notification form used was also missing the Ombudsman's address and information about appeal rights. The Director of Social Activities stated that notifications were not sent for all types of transfers, including those for observation stays, contrary to regulatory requirements.
Failure to Provide Consistent Range of Motion Services
Penalty
Summary
The facility failed to provide consistent and adequate range of motion (ROM) treatment and services to two residents with significant mobility limitations. One resident, admitted with hemiplegia affecting the left side and contractures in the left hand and both elbows, was observed multiple times without the prescribed right arm splint and left hand roll. Interviews with restorative staff confirmed that the resident was not receiving the required ROM exercises at the prescribed frequency, with documentation showing that both splint application and ROM exercises were only completed on a few days in April and May, rather than the six times per week as ordered in the care plan. Another resident, admitted with hemiplegia and hemiparesis following a stroke, was also not consistently provided with passive ROM (PROM) exercises as outlined in their care plan. Observations over several days showed the resident in bed with foot pads on, but no evidence of ROM activity during multiple shifts. Staff interviews revealed that PROM was not being provided at the required frequency due to staffing shortages, and the treatment administration record confirmed that PROM was only completed on a few days in April and May, rather than the three times per week specified in the care plan. The Director of Nursing acknowledged that both residents did not have consistent ROM completed, and staff interviews emphasized the importance of these interventions in maintaining mobility and preventing further contractures. The facility's own restorative program policy states the intent to help residents achieve and maintain their highest functional level, but the observed and documented care did not meet these standards for the two residents involved.
Failure to Provide Adequate Supervision and Safe Environment for Residents
Penalty
Summary
The facility failed to minimize the risk of preventable accidents for two residents by not providing adequate supervision and not ensuring a safe environment. One resident with a history of wandering, hemiplegia, dementia, and poor safety awareness was repeatedly observed walking unaccompanied in hallways and between units without staff supervision. Despite being identified as high risk for falls and serious injuries, and care plan interventions calling for close supervision or frequent visual checks, the resident was seen wandering alone on multiple occasions. Staff interviews confirmed that the resident required more supervision to ensure safety, and that her wandering behavior was sometimes upsetting to other residents. Another resident, identified as a current smoker with mobility limitations due to right hip osteoarthritis, was observed using a designated smoking area that did not meet facility policy requirements for safety. The area was unpaved, uneven, and surrounded by flammable plants and brush. There was no fire extinguisher present, and a plastic trash can with a thin liner was located near the smoking area. The resident and staff were observed disposing of cigarette butts in the plastic trash can instead of the required fire-proof receptacle. The DON confirmed that this was not in accordance with facility policy, which mandates a fire extinguisher and proper disposal of smoking materials in a fire-proof receptacle. The facility's policies on accident hazards and supervision require individualized interventions and environmental modifications to reduce risks, as well as specific safety measures for residents who wander and for designated smoking areas. The observed practices did not align with these policies, resulting in increased risk of avoidable accidents and injuries for the residents involved.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents requiring such services. One resident, who was non-verbal, bedbound, and had significant contractures to both hands, was observed without prescribed hand splints or hand rolls on multiple occasions. During passive range of motion (PROM) exercises, the resident exhibited clear signs of pain, such as deep facial grimacing and tightly closed eyes, yet was not pre-medicated for pain prior to the intervention. The staff member performing PROM acknowledged the resident's pain but continued the exercise until stopped by the surveyor. It was also found that the resident did not have any pain medication ordered prior to the incident, and staff were not consistently following care plan interventions for pain assessment and management. Another resident, whose preferred language was Vietnamese, was not assessed for pain in a manner she could understand. Despite her repeated attempts to communicate pain using picture cards and the Vietnamese word for pain, staff relied solely on the absence of facial grimacing to assess her pain level. The Wong-Baker Faces Pain Rating Scale, which should have been available for non-English speaking residents, was not present at the bedside, and staff were unfamiliar with the available picture cards. Pain assessments were consistently documented as zero, and pain medication was administered without proper assessment or communication with the resident in her preferred language. Both cases demonstrate a failure to accurately assess, monitor, and manage pain according to the residents' needs and care plans. The facility did not ensure that staff were adequately trained or equipped to recognize and respond to non-verbal or culturally specific expressions of pain, resulting in inadequate pain control and failure to maintain the residents' highest practicable level of well-being.
Failure to Ensure Residents Understand Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that three residents and their representatives fully understood the Binding Arbitration Agreement during the admission process. Interviews revealed that one family representative did not remember signing the agreement and was unaware of its contents, citing the overwhelming number of admission forms. Another resident stated she signed all admission papers but did not recall any discussion about the arbitration agreement and was unfamiliar with its details, indicating she would not have signed if she had known it waived her right to a traditional court trial. A third resident also did not remember signing the agreement or understanding its purpose, expressing indifference due to not having issues with the facility at the time. A staff interview with the Business Office Manager confirmed that the facility follows its policy regarding arbitration agreements during admissions. Review of the facility's policy indicated that residents and their representatives should be informed of the nature and implications of the agreement, including their right to refuse without affecting admission or continued care. The policy also requires that the agreement be explained in a manner and language the resident or representative understands, and that acknowledgment of understanding is obtained. Despite these policy requirements, the sampled residents and representative did not demonstrate understanding of the agreement, leading to the deficiency.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
Staff members failed to maintain resident dignity during mealtime assistance by not following facility protocols that require CNAs to sit at eye level with residents while feeding them. Multiple observations showed CNAs standing over residents while assisting with meals, mixing food, and intermittently leaving the residents unattended. In one instance, a CNA stood while feeding a resident, left to retrieve a meal tray, returned to stir the food, and then left again to assist another resident, before finally returning to continue feeding. These actions were observed to occur without the CNA sitting down to maintain eye contact or provide focused attention. Additionally, staff were observed conversing with each other about work matters instead of focusing on the residents they were assisting. Interviews with CNAs confirmed awareness that they should be sitting beside residents to ensure comfort and effective communication. An LPN interviewed was unsure of the proper procedure but acknowledged that residents should not feel intimidated. The DON confirmed that the facility's practice is for staff to sit at eye level with residents during meal assistance to promote dignity and communication. These observations and interviews demonstrate a failure to provide care in a manner that maintains resident dignity for all residents requiring meal assistance.
Failure to Include Resident Representatives in Care Planning
Penalty
Summary
The facility failed to ensure the inclusion of residents' representatives in the care planning process for two residents with severe cognitive impairment. One resident, who was observed to have dementia and a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, was unable to make significant decisions regarding his care. The resident's representative confirmed that while the resident could make minor day-to-day choices, he was not capable of making major decisions. Despite this, the representative was not invited to participate in the resident's care plan meeting and was not given the opportunity to provide input on the resident's goals, choices, and preferences. Documentation confirmed that only the resident was listed as attending the care plan meeting, and staff acknowledged that there was no record of the representative being notified or invited. For the second resident, also with severe cognitive impairment as indicated by a low BIMS score, the family representative reported that care planning meetings were sporadic and that formal meetings were not consistently conducted. Review of the electronic health record and interviews with staff confirmed that the last care planning meeting for this resident was held several months prior, and the required quarterly meeting was missed. The process for scheduling and documenting care planning meetings was described, but it was confirmed that the necessary meeting for this resident did not occur as required. These findings demonstrate that the facility did not facilitate the participation of residents' representatives in the care planning process for residents who were unable to make their own significant care decisions. As a result, the representatives were not able to support or provide input on the residents' care plans, which is a requirement for residents with severe cognitive impairment.
Medications Left at Bedside Without Clinical Assessment for Self-Administration
Penalty
Summary
A resident with moderately impaired cognitive skills, as documented in her Minimum Data Set (MDS) assessment, was found to have at least six different medications left at her bedside for self-administration. The resident did not respond verbally to questions about the medications. Nursing staff confirmed that the medications were her morning doses and acknowledged that medications should not be left at the bedside. The nurse responsible for leaving the medications stated he was working an extra shift and gave out medications early, confirming he should not have left them unattended. Further review of the resident's electronic health record revealed no assessment had been completed to determine if she was clinically appropriate to self-administer her medications. The Director of Nursing confirmed the absence of such an assessment and stated that, given the resident's cognitive status, she would not be appropriate for self-administration. The facility's policy on self-administration of medications was requested but not provided before the survey exit.
Failure to Accommodate Resident Shower Preferences and Ensure Mechanical Lift Availability
Penalty
Summary
The facility failed to accommodate the shower preferences and transfer needs of a resident who was fully dependent on staff for mobility and required a mechanical lift for transfers. The resident, who could not bend her knees, was unable to use the available shower chairs, including a reclining model that still required knee flexion. As a result, she only received bed baths instead of showers, despite her and her family’s expressed preference for weekly showers. Staff interviews confirmed that there were no shower gurneys available on the floor or in the facility to meet the needs of residents who could not sit up or safely use a shower chair. Additionally, the facility did not ensure the continuous availability of a mechanical lift for the nine residents on the floor who required it. There was only one mechanical lift on the floor, which was sometimes taken to other floors, leaving residents without access to necessary transfer equipment. Staff confirmed that the single lift was insufficient to meet the needs of all residents requiring mechanical assistance, and that the lack of equipment directly impacted the ability to provide appropriate care.
Failure to Honor Resident's Shower Preference
Penalty
Summary
A deficiency was identified when the facility failed to honor and support a resident's preference for showering. The resident, a female admitted for long-term care, was fully dependent on staff for toileting and required maximal assistance for showering and personal hygiene. Her Minimum Data Set (MDS) assessment indicated that it was somewhat important for her to choose between a tub bath, shower, bed bath, or sponge bath. Despite this, the facility did not identify or document her specific bathing preference. The resident's family representative reported that the resident wished to have a shower at least once a week but was only provided with bed baths, a concern that had been communicated to staff. Interviews with facility staff revealed a lack of awareness regarding the resident's preferences. A Certified Nurse Aide (CNA) confirmed that the resident was scheduled for baths twice a week but only received bed baths, and was unaware of any specific shower preference. The Director of Nursing (DON) acknowledged during a review that the facility had not identified or documented the resident's choice regarding bathing method. The facility also failed to secure the necessary equipment to accommodate the resident's shower preference, resulting in her needs not being met and hindering her from attaining her highest practicable well-being.
Failure to Provide Quarterly Personal Fund Statements to Residents
Penalty
Summary
The facility failed to provide quarterly personal fund statements directly to two residents who maintained trust accounts with the facility. Both residents were determined to be their own responsible persons and were cognitively intact or nearly intact, as indicated by their BIMS scores. Despite facility policy requiring quarterly statements to be provided to residents and/or their responsible parties, the statements were only sent to addresses on file, which were not the facility addresses where the residents resided. Interviews with the residents confirmed that they did not receive their statements unless specifically requested, and in one case, the statements were sent to a family member instead of the resident. The Business Office Manager (BOM) confirmed that there was no documentation or tracking system in place to verify that statements were delivered to the residents. The BOM acknowledged that, despite a previous citation for the same issue, there was no evidence that the residents had received their statements as required. As a result, the residents were not made aware of their current account balances and were not given the opportunity to periodically reconcile their accounts, as stipulated by facility policy.
Failure to Secure Electronic Health Records at Documentation Station
Penalty
Summary
Surveyors observed that an ICARE documentation station, used by CNAs and RNAs to record resident care tasks and interactions, was left open and accessible in a high-traffic hallway near the entrance to a wing. The open station displayed a resident's personal and clinical information, including code status, allergies, diet, and required treatment monitoring. Staff interviews confirmed that the station should have been closed and exited out after use to maintain privacy and comply with HIPAA requirements. The Director of Nursing and other staff acknowledged that leaving the station open was not in accordance with facility policy or privacy regulations. Review of the facility's policy confirmed the expectation for privacy and confidentiality of resident records.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents. One resident was observed multiple times in her room with fall mats on both sides of her bed that were dirty with black marks. Despite repeated observations over several days, the condition of the mats did not change, and a housekeeper was unable to confirm when the mats were last cleaned, acknowledging their dirty state. Another resident was consistently observed sitting in a hallway area directly beneath a ceiling tile with a large black spot. Nursing staff were unaware of the dirty ceiling tile and had not reported it to maintenance. The issue was only addressed after it was pointed out by a surveyor. The maintenance supervisor later indicated the damage might have been from an old leak, but could not determine the source, and the tile was found to be dry.
Failure to Accurately Assess Resident Status Due to Incomplete Observation and Language Barriers
Penalty
Summary
The facility failed to conduct accurate assessments for two residents, resulting in their needs not being properly identified or met. One resident, a female with severe cognitive impairment, left-sided weakness from a stroke, and a history of falls, was observed wandering unsupervised on and off the unit over several days. Despite these observations and the daily use of a wander/elopement alarm, her Minimum Data Set (MDS) quarterly review did not code her as exhibiting wandering behaviors. The MDS coordinator stated that wandering may not have been observed during the assessment period, but the surveyor noted multiple documented instances of wandering during that time. Another resident, a female admitted for long-term care with a preferred language of Vietnamese, was marked as "rarely/never understood" on her MDS Annual Assessment, and the Brief Interview for Mental Status (BIMS) was not conducted. The Social Services Director attempted the assessment using a phone interpreter in Cantonese, which was not the resident's language, resulting in poor communication. The resident's family confirmed she only speaks Vietnamese and demonstrated during an interview that she could communicate effectively when interpreted correctly. The facility's policy requires accurate documentation of residents' medical, functional, and psychological status, which was not followed in these cases.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, resulting in unmet medical, physical, mental, and psychosocial needs. For one resident with vascular dementia, hemiplegia, and incontinence, the care plan addressed incontinence and skin integrity, but observations revealed improper peri-care technique by a CNA, including wiping from back to front, which was acknowledged as incorrect by both the CNA and the DON. This improper technique was observed during a brief change, and new areas of skin breakdown were identified, despite the care plan's goal to prevent such issues. Interviews with staff confirmed inconsistent knowledge and application of proper peri-care procedures, and the resident's care plan did not fully address her needs or prevent the decline in skin condition. Another resident, whose preferred language is Vietnamese, did not have a care plan that included a person-centered communication plan or interpreter services, despite this being identified as a need. This omission meant that the resident's communication preferences and needs were not accurately reflected or addressed in her care plan, potentially impacting her ability to communicate effectively with healthcare staff. A third resident with a history of trauma and mental health diagnoses did not have a trauma-informed care plan that included identified triggers and specific interventions, even though the facility's policy required such plans. The resident's psychosocial evaluation documented anxiety related to large crowds, but this was not incorporated into the care plan. The lack of individualized, comprehensive care planning for these residents resulted in deficiencies that placed them at risk for a decline in their quality of life and prevented them from attaining their highest practicable well-being.
Failure to Revise Care Plan and Provide Intervention for Dialysis Access Site
Penalty
Summary
The facility failed to revise the care plan for one resident receiving dialysis and did not provide an intervention for the resident's dialysis access site after returning from dialysis with a pressure dressing in place. The resident, who has a history of end stage renal disease, hypertensive heart and chronic kidney disease, diabetes, dementia, and dependence on renal dialysis, was observed with a dressing on his upper left arm after returning from dialysis. The resident reported that the dressing was applied at the dialysis center and that sometimes nurses at the facility remove it and apply Band-Aids if there is still bleeding. Review of the resident's care plan showed it included monitoring for complications from hemodialysis, avoiding blood draws or blood pressure measurements on the arm with the arteriovenous fistula, encouraging attendance at dialysis appointments, and monitoring for signs of infection or renal insufficiency. However, the care plan did not include specific interventions for the care of the dialysis access site or removal of the pressure dressing after dialysis. Interviews with nursing staff revealed inconsistent practices regarding who is responsible for removing the pressure dressing and when it should be removed. One nurse stated that the night shift is responsible, while another indicated that the dressing is usually removed within two hours of the resident's return from dialysis, but confirmed it was not removed as expected. The Director of Nursing confirmed that there was no established protocol for the removal of the pressure dressing prior to contacting the dialysis center for guidance. The lack of a clear intervention in the care plan and inconsistent staff practices resulted in the resident retaining the pressure dressing for an extended period after returning from dialysis, without appropriate assessment or intervention documented in the care plan.
Failure to Provide Communication Supports for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide appropriate care and treatment to support the communication abilities of two residents whose primary languages were not English. Upon admission, both residents were identified as needing interpreter services and alternative communication methods, but the facility did not implement effective person-centered communication plans. For one resident who spoke only Vietnamese, the care plan inaccurately listed her primary language as both Cantonese and Vietnamese, and there was no evidence that interpreter services were used. The resident's family representative confirmed that interpreter services were never offered or used, and staff did not request her assistance to interpret. Observations revealed that communication aids, such as picture cards with Vietnamese words, were not accessible at the bedside, and there were no pain scale cards available to assess the resident's pain level. For the second resident, whose preferred language was Mandarin, the facility's staff were unaware of the available professional translator service and could not locate the communication board intended for the resident's use. The communication board was found on the roommate's side of the room, out of reach. Interviews with staff revealed that they primarily relied on gestures to communicate and were not aware of the translator service or the communication tools that should have been available. The facility's policy required the use of communication methods in a language familiar to the resident, but this was not followed in practice. These deficiencies were identified through observation, interviews, and record review, and demonstrated that the facility did not ensure residents with limited English proficiency had access to necessary communication supports. As a result, the residents were at increased risk of not having their needs met and were hindered from attaining their highest practicable well-being.
Failure to Timely Remove Dialysis Pressure Dressing and Assess Access Site
Penalty
Summary
A resident who required dialysis returned to the facility with a pressure dressing still in place on their left forearm fistula after a morning dialysis session. The resident reported that the nurse typically removes the dressing after returning from dialysis. However, observations revealed that the pressure dressing remained on the resident's arm into the following morning. The resident stated that the dressing had been removed the previous night but was reapplied by the night shift nurse due to continued bleeding. The pressure dressing was not removed until late the next morning, after it was brought to the attention of the registered nurse, who had not been informed by the night shift about the status of the dressing and had not yet assessed the access site due to the resident's early appointment. The Director of Nursing confirmed that the pressure dressing should be removed a few hours after dialysis and the access site checked for bleeding every shift, unless there are specific physician orders to leave the dressing on. The dialysis provider advised that if bleeding is present, the dressing may remain for a couple of hours but should be assessed every two to three hours and removed once bleeding stops. The failure to remove the pressure dressing in a timely manner and to properly communicate and assess the access site led to the deficiency.
Failure to Timely Assess and Identify Resident Trauma History
Penalty
Summary
The facility failed to adequately assess and identify past trauma for a resident admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder. Upon review, it was found that no trauma screening was conducted at the time of admission, despite the facility's policy requiring such screening. The psychosocial assessment, which included only one question about trauma, was not completed until more than two months after admission. Additionally, the Social Services Life Event Checklist, intended to assist in creating a trauma-informed care plan, was not completed in a timely manner and all responses were marked as not applicable. Interviews with the Social Services Director and staff revealed that there was no formal trauma screen form in use, and the required trauma-informed care training had only been completed by the Social Services Director, with no evidence of completion by other social services staff. The resident, who is cognitively intact, disclosed a significant traumatic event from his past during an interview, which had not been previously identified or addressed in his care planning.
Failure to Provide Person-Centered Behavioral Health Services and Supervision
Penalty
Summary
The facility failed to provide necessary behavioral health care and services that were person-centered and reflected the resident's goals for care, specifically for one resident with a history of hemiplegia, hemiparesis, and dementia. This resident was observed multiple times wandering unsupervised in hallways and other units, taking food from other residents' trays and rooms, and displaying aggressive behaviors such as hitting and making threatening gestures. Other residents and staff reported ongoing distress and complaints about these behaviors, noting that staff responses were limited to redirection and explanations rather than increased supervision or intervention. Interviews with residents, staff, and social services personnel revealed that the underlying causes of the resident's behaviors were not clearly understood or documented in the care plan. The care plan included general interventions such as providing supervision and offering assistance, but observations showed that these measures were inconsistently implemented. Staff and social services acknowledged the need for more supervision and indicated that referrals to psychiatric services were delayed or not current, with the last psychiatric evaluation dated two years prior. Facility policy required the provision of medically related social services and timely referrals for mental and psychosocial counseling, but documentation and interviews indicated that these processes were not effectively followed. The lack of timely psychiatric evaluation, insufficient supervision, and inadequate person-centered behavioral interventions contributed to ongoing behavioral issues that affected both the resident and others on the unit.
Early Medication Administration and Incomplete Narcotic Count Documentation
Penalty
Summary
A deficiency was identified when a registered nurse administered morning medications to a resident more than two hours before the scheduled time, without ensuring the required safety parameters were met. The medications, which included blood pressure medications with specific hold parameters, were left at the resident's bedside before they were due. The nurse did not obtain or verify the resident's vital signs prior to administration, instead relying on data from a certified nurse aide whose shift had not yet started, making it impossible for the data to have been available at the time of administration. The nurse later confirmed that medications for multiple residents were given early to accommodate his work schedule. Further review revealed that the medication administration record was inaccurately documented, as the nurse recorded the medications as being given on time, despite administering them early. The facility's policy requires medications to be administered within one hour of the scheduled time and for vital signs to be obtained and recorded when applicable. The nurse's actions were inconsistent with these policies, and the nurse supervisor confirmed that this practice should not occur. Additionally, a separate deficiency was noted regarding the facility's narcotic count procedures. During a medication cart audit, it was found that the narcotic count sheet was not fully completed, with missing signatures and verification fields for both the day and afternoon shifts. The director of nursing confirmed that licensed staff are required to sign the narcotic count sheet after reconciliation, as outlined in the facility's policy. The incomplete documentation failed to ensure proper accountability and reconciliation of controlled substances.
Failure to Act on Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that recommendations made by the consultant licensed pharmacist (CLP) during the monthly medication regimen review (MRR) were acted upon for a resident. Specifically, for a male resident with diagnoses including spinal stenosis, atrial fibrillation, and anxiety disorder, one MRR recommendation regarding a gradual dose reduction (GDR) or clinical contraindication (CC) for Trazadone was not followed up in a timely manner. Although a provider eventually declined the recommendation, documentation of timely review and follow-up was lacking. Additionally, another MRR recommendation noted the discontinuation of Trazadone and the initiation of Lexapro, with a plan to discuss the change at the next psychotropic meeting. However, there was no documentation available to confirm that this discussion took place, as the requested psychotropic meeting minutes were not provided. The DON confirmed that unit managers are responsible for reviewing MRRs within one week, but the absence of documentation indicates this process was not consistently followed.
Medication Storage, Labeling, and Administration Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the storage, labeling, and administration of medications. One resident was found sitting in a wheelchair with a medication cup containing pills and a loose pill on the table, while the assigned RN was distracted and not directly supervising the resident. The RN did not immediately notice the loose pill until prompted by the surveyor. The facility's policy and the DON confirmed that nurses are required to observe residents taking their medications, which was not followed in this instance. Additional observations included improper storage and labeling of medications in the medication cart. Discontinued and unlabelled medications were found stored with active medications, including controlled substances not being properly counted or removed after discontinuation or resident discharge. The DON confirmed that these medications should have been removed and disposed of according to facility policy, but this was not done. These actions and inactions resulted in medications not being stored, labeled, or administered in accordance with professional standards.
Failure to Accommodate Resident Food and Drink Preferences
Penalty
Summary
A resident with diagnoses including diabetes, end stage renal disease, hemodialysis, heart failure, and high cholesterol was not provided with food and drink that accommodated his stated preferences. Despite repeated requests over several weeks for specific items such as a turkey sandwich with cheese for lunch, tea instead of milk, and dry cereal for breakfast, these preferences were not honored by the facility. As a result, the resident refused to eat the food provided by the facility and relied on outside food brought in by family members, leading to feelings of malnourishment and weakness. Interviews with staff revealed ongoing miscommunication between nursing and kitchen staff regarding the resident's diet waiver, which allowed him to eat preferred foods. The Food Services Director acknowledged the miscommunication and confirmed that the resident's preferences had not been consistently accommodated. Facility policy requires that food and drink be provided in accordance with resident preferences, but this was not followed in the resident's case.
Failure to Properly Label and Discard Resident Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During an observation in the kitchenette, one food container was found labeled with a resident's name but without a date, and another container was labeled with a resident's name, room number, and a date that was seven days old. When questioned, the Restorative Nurse Aide (RNA) stated that the process is to label food with the resident's name, date, and room number, and to discard it after three days. The RNA acknowledged the improper labeling and agreed that the food should be discarded. These findings were confirmed with an LPN and an RN present at the nurses station. Further interview with a kitchen staff member clarified that the kitchen is responsible for maintaining the nourishment refrigerators and food from the kitchen, while nursing staff are responsible for labeling and discarding food brought in from outside or saved after meals. The facility's policy requires outside food to be labeled with the resident's name, room number, and date, and stored in a designated refrigerator. However, the facility did not provide a policy specifying how long food items should be stored before being discarded.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for one resident by not documenting medication administration in accordance with accepted professional standards. Specifically, a registered nurse administered at least six different medications to the resident more than two hours before the scheduled 09:00 AM time, but did not document the administration until approximately 08:50 AM, which was only ten minutes before the medications were due. The nurse confirmed that the medications were given early and that the documentation did not reflect the actual time of administration, as the electronic health record system did not allow for documentation more than one hour before the scheduled time. Observations at the resident's bedside confirmed the presence of the medications on the table, and interviews with both the nurse supervisor and the Director of Nursing verified that facility policy requires medications to be administered no more than one hour before or after the scheduled time and that documentation should occur immediately after administration. The inaccurate documentation made it appear as if the medications were given on time, when in fact they were not, and this was acknowledged by both the nurse and the Director of Nursing as not aligning with facility and nursing standards.
Failure to Maintain Medication Refrigerators and Thermometers in Safe Operating Condition
Penalty
Summary
Surveyors observed that the facility failed to maintain essential medication storage equipment in safe operating condition. During an inspection of the third floor medication storage room, the freezer compartment of the medication refrigerator was found to be completely frozen with ice, and a clear plastic bag containing an unidentified object was frozen into the ice. The registered nurse present confirmed the need for defrosting and was unable to identify the contents of the frozen bag. In a separate medication storage room, the thermometer for the medication refrigerator displayed a temperature of 60 degrees, which is above the facility's recommended range of 36-46 degrees. The refrigerator contained IV antibiotics, insulin, and immunization vials. The previous temperature logs were within the recommended range, but the current elevated temperature was attributed by staff to overstocking and frequent opening of the refrigerator. When questioned about the process for addressing out-of-range temperatures, the registered nurse stated she would recheck the temperature in a few hours and notify the unit manager or maintenance assistant if the issue persisted. The maintenance assistant, when asked about maintenance schedules, indicated there was no set schedule for checking or maintaining the refrigerators and thermometers, and that issues were addressed only when reported by staff. The director of nursing confirmed the importance of maintaining working thermometers to ensure medication efficacy. The facility's medication storage policy requires regular monitoring of storage conditions as a quality assurance measure.
Failure to Prevent and Respond to Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from all forms of abuse, specifically resident-to-resident physical abuse, as evidenced by multiple incidents involving several residents. In one case, a resident with severe cognitive impairment and limited mobility was physically assaulted by his roommate, who had a known history of aggressive behavior. Despite the facility's awareness of the perpetrator's behavioral risks, the two residents continued to share a room, and there was no documentation that the victim or his representative was informed in a language they could understand about the option to move rooms. The victim sustained physical injuries and experienced pain, and the full extent of psychosocial harm could not be determined due to communication barriers. Additional incidents included a witnessed altercation between two other residents, where one punched the other in the hallway after a verbal dispute, and another case where a resident kicked his roommate during an argument over a wheelchair. In both cases, the facility's investigative reports failed to substantiate abuse despite eyewitness accounts and documentation in progress notes that confirmed physical aggression occurred. Furthermore, there was a lack of adequate supervision during a verbal and physical altercation between two residents in a common area, as staff left the area unsupervised, leaving residents in an unsafe environment. The facility's documentation and investigative practices were inconsistent and incomplete, with missing or inadequate records of incidents, lack of communication with residents and their families, and failure to follow policies designed to prevent and prohibit abuse. The facility did not take immediate and appropriate steps to protect residents from further harm once abuse was identified, nor did it ensure that residents with known behavioral risks were managed in a way that prevented recurrence of abuse.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility, licensed for 288 beds, failed to employ a qualified full-time social worker as required for facilities with more than 120 beds. The Administrator confirmed that the current Social Services Director (SSD) did not possess the minimum required credentials, such as a bachelor's degree in social work or a related human services field. Employment documentation review revealed that the social services staff, including the Social Services Assistant (SSA) 1, SSA2, and SSA3, did not meet the qualifications for a social worker, with SSA1 lacking both the necessary experience in a health care setting and direct work with individuals, and SSA2 and SSA3 also not meeting the definition of a qualified social worker. Interviews with the SSD and SSA1 further confirmed the absence of required educational background and relevant work experience among the social services staff.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate two separate resident-to-resident abuse allegations, as evidenced by incomplete documentation and lack of witness statements. In the first incident, a resident-to-resident abuse allegation occurred involving two residents. The investigation packet included a statement from the first staff member on the scene, a Unit Manager, who called for assistance from a Physical Therapist. However, the facility did not obtain a witness statement from the Physical Therapist, who was also present at the scene. The Administrator confirmed that a statement from this staff member should have been included to ensure a comprehensive investigation. In the second incident, two residents were involved in a verbal and physical altercation during a group activity. The facility's event report included written accounts from three staff members who witnessed the event. The Director of Nursing stated that she interviewed these staff members but could not provide documentation of the interviews. Additionally, no interviews were conducted with other residents who attended the activity where the altercation occurred. The facility's policy requires identifying and interviewing all involved persons and witnesses, but this was not followed in these cases.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) at least two days prior to the end of Medicare-covered services for one resident. During a state agency complaint investigation, it was found that the responsible party for the resident received the NOMNC via email on the same day that Medicare services were set to end, rather than the required advance notice. Interviews with the Social Services Director and Social Services Assistant confirmed that the notice was not issued in a timely manner, and a progress note was incorrectly dated, further indicating the notice was not provided as per policy. The facility's own policy requires that the NOMNC be issued at least two days before the end of a Medicare Part A stay, which was not followed in this instance.
Failure to Report Resident-to-Resident Physical Abuse to Law Enforcement
Penalty
Summary
The facility failed to report allegations of resident-to-resident physical abuse to law enforcement in three separate incidents, despite its own policy requiring such reports for any reasonable suspicion of a crime, including assault and battery. In each case, the facility deferred to the wishes of the residents or their families, who declined to involve law enforcement, even though the incidents involved physical altercations. For example, one incident involved a resident with a history of physical aggressiveness assaulting another resident, and another involved two residents physically assaulting each other. In a third case, a resident punched another after a verbal altercation, and the family of the victim declined to pursue charges or contact the police. Interviews with facility leadership, including the Administrator and DON, confirmed that law enforcement was not notified in any of these cases because the residents or their families did not want police involvement. The facility's actions were inconsistent with its policy, which mandates reporting all reportable incidents to law enforcement regardless of resident or family preference. These failures were identified during a State Agency investigation and were documented in the facility's records and staff interviews.
Failure to Provide Psychosocial Follow-Up After Abuse Allegation
Penalty
Summary
The facility failed to provide medically-related social services to a resident following an allegation of resident-to-resident physical abuse. After the incident, there was no documentation of psychosocial follow-up for the resident, who was the alleged victim. The resident had severe cognitive impairment, as indicated by a BIMS score of 6 out of 15, and preferred to communicate in Mandarin, requiring an interpreter for effective communication with healthcare staff. Despite this, the only depression screening conducted since admission was performed with input from staff who did not communicate with the resident in his preferred language, and no interpreter or family assistance was used. Interviews with facility staff confirmed that the expected process for abuse allegations includes a 72-hour psychosocial follow-up focused on the alleged victim, but this was not completed or documented for the resident in question. The social services assistant and administrators acknowledged the lack of psychosocial follow-up, and the electronic health record review corroborated the absence of such documentation. The failure to provide appropriate psychosocial support hindered the resident's ability to attain or maintain his highest practicable psychosocial well-being.
Failure to Maintain Accurate Medical Records for NOMNC Issuance
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident, as required by accepted professional standards. Specifically, there was a discrepancy in the documentation and issuance of the Notice of Medicare Non-Coverage (NOMNC) for the resident. The family member responsible for the resident received the NOMNC via email on 04/08/25, indicating that services would end on that date. However, the resident's electronic health record (EHR) contained a scanned copy of the NOMNC with handwritten information stating it was issued on 04/04/25, and a social services note also documented the NOMNC as being issued on 04/04/25. During interviews and record review, the Social Services Assistant confirmed that the NOMNC was actually issued on 04/08/25, not 04/04/25 as documented in both the EHR and the social services note. This inconsistency in documentation demonstrates a failure to maintain accurate medical records for the resident.
Failure to Document and Investigate Resident Grievance
Penalty
Summary
The facility failed to document a verbalized complaint as a grievance for a resident, which violated the resident's right to have her grievance investigated, resolved, and be informed about the resolution. The incident involved a female resident who was admitted for short-term rehabilitation following a loss of consciousness and a fall. The resident reported to the Unit Manager that a CNA and an RN on the overnight shift refused to change her adult incontinence brief when requested. Additionally, the resident overheard the CNA telling other staff and her roommate that she was lying about needing her brief changed. The Social Worker, who shared the Grievance Officer role with the Administrator, confirmed that the grievance was not logged as per the usual process. The Unit Manager reported the incident during a Stand-Up meeting and filled out a Grievance Form, which was turned in to the Director of Nursing. However, the Administrator stated that there was never a Grievance Form regarding the incident. The facility's policy allows grievances to be submitted orally or in writing, but in this case, the grievance process was not followed, and the resident's complaint was not documented or investigated as required.
Failure to Implement Employee Screening Policy
Penalty
Summary
The facility failed to implement its policy to screen potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. This deficiency was identified during an investigation of an incident involving a resident who reported neglect by staff members. The resident, admitted for short-term rehabilitation following a loss of consciousness and fall, alleged that a CNA and an RN refused to change her adult incontinence brief upon request. During the investigation, the facility was unable to provide the criminal background check for the CNA, which was required by their policy. Although the background check for the RN was eventually provided, the CNA's background check remained outstanding, indicating a lapse in the facility's adherence to its screening procedures.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written transfer notifications to residents or their representatives before transferring them to an acute care hospital. This deficiency was identified for five residents, indicating a systemic issue with the facility's adherence to its own policy on admissions, transfers, and discharges. The policy requires that residents and their representatives be notified in writing, in a language and manner they understand, about the transfer or discharge and the reasons for the move. However, record reviews and interviews revealed that this procedure was not followed for any of the sampled residents. Specifically, the report highlights that a 66-year-old female resident, along with four other residents, were transferred to acute care hospitals without receiving the required written notifications. Interviews with the facility's social worker confirmed that the facility does not provide written notifications of transfer or discharge to residents or their representatives when they are sent to acute care. This practice was consistent across all five cases reviewed, demonstrating a failure to comply with regulatory requirements and the facility's own policies.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives during transfers to acute care hospitals or therapeutic leave. This deficiency was identified through record reviews and interviews, affecting five sampled residents. The facility's policy, revised in March 2023, mandates that written information about the bed hold policy be given to residents or their representatives before a transfer or therapeutic leave and at the time of transfer. However, for all five residents sampled, there was no documentation in their electronic health records (EHR) indicating that such notifications were provided. Specific cases include a female resident transferred to a hospital on May 2, 2024, without her representative receiving the required notification. Another resident was transferred on June 28, 2024, for a wound infection and gangrene, yet no notification was documented. Similarly, a resident transferred for a femur fracture and pneumonia, and another for shoulder pain, also lacked documentation of notification. Interviews with the social worker confirmed that the facility did not provide written notifications of the bed hold policy to residents or their representatives during these transfers.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily at the beginning of each shift in a prominent place readily accessible to residents and visitors. On multiple occasions, surveyors observed that the nurse staffing data was not posted on Unit 3, Unit 2, or Unit 4, nor at the entrance of the facility or near the elevators. When the staffing data was eventually found, it was noted to be outdated and did not provide specific information for individual units, only for the entire facility. Interviews with the Unit Manager and the Director of Nursing revealed a lack of awareness and compliance with the facility's policy regarding the posting of nurse staffing information. The Unit Manager was unaware of where the postings were supposed to be, and the Director of Nursing confirmed that the postings did not include unit-specific information. The facility's policy required that the postings include the facility name, current date, total number and actual hours worked by nursing staff per shift, and resident census, in a format accessible to residents and visitors, which was not adhered to.
Deficiency in Conducting Comprehensive Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings for residents were conducted quarterly and that these meetings were attended by an interdisciplinary team (IDT) that included the attending physician, registered nurse, nurse aide, and the resident's representative(s). For Resident 58, the most recent IDT meetings only included social services and recreation services staff, excluding the attending physician, registered nurse, and nurse aide. This was confirmed by both the resident and the Director of Nursing (DON). Similarly, Resident 168 reported not being invited to his care plan meeting, and records showed that only social services and recreation staff attended, with no documentation of the attending physician, registered nurse, or nurse aide's presence. Resident 253 also did not recall attending a care plan meeting, and records indicated that only social services, a registered dietician, and recreation staff were present, with no attending physician, registered nurse, or nurse aide. Resident 38 expressed a desire to attend care plan meetings but was not given the option, as the facility used outdated invitation letters from the COVID period that restricted in-person attendance. The DON confirmed that all IDT members, including the physician and registered nurse, should be present for care plan meetings, but this was not the case for the residents mentioned.
Staffing Deficiencies Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, impacting their quality of life and well-being. Observations and interviews revealed that the facility did not provide adequate staffing, particularly in the provision of Restorative Nurse Assistant (RNA) services, which are crucial for preventing and minimizing contractures in residents. This deficiency was noted in the care of two residents, R199 and R20, who did not receive the necessary services as scheduled. During interviews with resident council members, it was reported that the facility was consistently short-staffed, with fewer certified nurse's aides (CNAs) than required based on the units' acuity and census. Residents expressed concerns about the lack of one-on-one supervision for those who needed it, and the impact of floaters who were unfamiliar with residents' routines. The resident council minutes from May to July 2024 documented ongoing issues with staffing shortages, with residents repeatedly requesting more CNAs on the floors. Further interviews and record reviews highlighted specific instances of staffing shortages. On several occasions, the number of CNAs scheduled did not meet the facility's own CNA matrix requirements, leading to higher resident-to-CNA ratios than recommended. For example, on certain days, units had ratios as high as 1:16, significantly exceeding the intended 1:7 ratio. Residents reported delays in receiving care, such as longer wait times for assistance, meals, and wound dressing changes, which were attributed to the insufficient staffing levels.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure appropriate infection prevention and control measures, as evidenced by multiple instances of staff not following standard precautions. A registered nurse (RN16) was observed changing a dressing on a gastric tube insertion site without wearing a gown and did not perform hand hygiene between glove changes or after doffing gloves. Additionally, RN16 admitted to not having access to alcohol-based hand rub (ABHR) at the bedside, which is against facility policy. Another incident involved a unit manager (UM4) who adjusted a resident's nasal cannula without performing hand hygiene. Further observations revealed a certified nurse aide (CNA12) moving between residents and handling meal trays without performing hand hygiene. A registered nurse (RN5) also failed to perform hand hygiene between glove changes while administering medications. Additionally, CNA13 did not disinfect a shared blood pressure cuff after use. The Director of Nursing confirmed that these actions were against the facility's infection prevention and control policy, which mandates hand hygiene and the decontamination of multi-use equipment.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by several incidents involving four residents. Resident 50, who is cognitively intact but dependent on staff for various activities, reported having to wait over 30 minutes for assistance after activating the call light. This delay left her sitting in her waste, causing discomfort and a sense of neglect. Additionally, staff did not communicate with her about the delay, nor did they knock or announce themselves when entering her room, particularly float staff who were perceived as rushing through tasks without considering resident preferences. Resident 50 also experienced disturbances at night due to staff speaking loudly while assisting another resident, affecting her sleep and ability to participate in exercises safely. Resident 113, also cognitively intact and dependent on staff, reported similar issues with long wait times for call light responses, sometimes up to an hour, without staff checking in to provide updates. This lack of communication and delay in assistance further exemplifies the facility's failure to respect residents' dignity and needs. Resident 29 experienced confusion and distress after being moved to a different room without her personal belongings following a hospital stay. Her family member confirmed that the facility did not communicate the room change or transfer her belongings, leading to her wearing a hospital gown instead of her clothes, which she preferred for activities. Additionally, concerns were raised about a specific Certified Nurse's Aide (CNA13) who was reported by residents to be disrespectful and unproductive. Observations confirmed that CNA13 was not actively engaged in resident care and was using personal electronic devices in residents' rooms, contrary to facility policy. This behavior was corroborated by other staff members and the Director of Nursing, who stated that personal devices should not be used for charting or left in residents' rooms. These incidents collectively highlight the facility's failure to uphold residents' rights to dignity, respect, and a personalized living environment.
Failure to Ensure Resident Representative's Rights
Penalty
Summary
The facility failed to ensure that a resident's representative, identified as the Durable Power of Attorney (DPOA) for a resident with Alzheimer's Disease, was able to exercise the resident's rights as required by state law. The resident, who had severe cognitive impairment and was unable to make medication-related decisions, had an informed consent form for the use of an antidepressant medication signed by the resident instead of the representative. The form lacked necessary details such as the signature and date of the responsible party, and there was no documentation of verbal consent from the representative. Additionally, the facility documented that the representative attended an interdisciplinary care plan meeting and declined certain services for the resident, but further review revealed that the representative did not participate in the meeting. Interviews with facility staff confirmed the resident's inability to understand medication-related information and the lack of documentation supporting the representative's involvement in decision-making. The Director of Nursing acknowledged discrepancies in the documentation and could not explain the inconsistencies in the informed consent form dates.
Failure to Accommodate Shower Preferences for Residents
Penalty
Summary
The facility failed to honor the shower preferences of two residents, leading to a deficiency in accommodating their needs. Resident 171, a cognitively intact male with multiple health conditions including heart disease and diabetes, was observed wearing a soiled gown and reported receiving only monthly bed baths despite his care plan indicating he should receive showers twice a week. Interviews with staff revealed a misunderstanding, as the resident was receiving bed baths instead of showers, contrary to his care plan. Similarly, Resident 199, who is cognitively intact and diagnosed with ALS, expressed frustration over not being allowed to shower despite requesting it multiple times. The resident was informed that a shower gurney was reserved for another resident, although the facility did not possess a proper shower gurney. Staff interviews confirmed the lack of equipment to accommodate the resident's shower preference, leading to the deficiency in meeting the resident's needs as outlined in his care plan.
Failure to Provide Resident with Personal Funds Statements
Penalty
Summary
The facility failed to ensure that a resident's individual financial record was made available to her through quarterly statements. The resident, a cognitively intact female with a history of left-sided paralysis and weakness following a stroke, heart disease, peripheral vascular disease, and lymphedema, reported not receiving any statements regarding her personal funds since her admission. During an interview, she expressed uncertainty about her account balance, suspecting that her sister in Texas might be receiving the statements instead. The Business Office Manager (BOM) confirmed that the facility's practice was to send quarterly statements to the responsible party, but in this case, the resident was responsible for herself. The BOM could not recall if the statements were being sent to the resident or her daughter. Upon review, it was confirmed that the statements were sent to the sister's address in Texas, and the resident had not been issued a copy. The Assistant Administrator verified that the last quarterly statement was indeed sent to the sister's address, indicating a failure to provide the resident with her financial information.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by several observations and interviews. A resident expressed dissatisfaction with the physical state of the building, noting peeling wallpaper and exposed drywall in the restorative room and throughout the unit, as well as water-damaged ceiling tiles. The resident reported that the unit's appearance negatively impacted her well-being. The Director of Maintenance confirmed these observations. Another resident was placed in a room with peeling paint, which was only addressed after she moved back to her previous room. The maintenance department did not receive a work order to fix the room before the resident was placed there. Additionally, a resident reported that her toilet had not been flushing properly for weeks, which she found unsanitary. The toilet was shared with three other residents. Despite previous work orders and maintenance attempts to fix the toilet, it continued to malfunction due to a bent handle and an offset seal. The Director of Maintenance acknowledged the issue and confirmed that the toilet would not function properly until these problems were addressed.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints that were not required for medical treatment. The resident, a female admitted for long-term care, was observed lying in a Geri-chair that was fully reclined with a wheelchair wedged under the extended footrest. This setup prevented the resident from being able to adjust the chair independently, effectively acting as a physical restraint. The facility's policy defines a physical restraint as any device that is attached or adjacent to the resident's body, cannot be easily removed by the resident, and restricts the resident's freedom of movement. During an interview, the Nurse Manager acknowledged that the use of the wheelchair in this manner constituted a physical restraint and should not have occurred. The resident in question required frequent supervision and medication adjustments due to restless and anxious behavior and a history of falling. However, the use of physical restraints was deemed inappropriate for managing these symptoms. This oversight resulted in a violation of the resident's rights and placed her at risk of avoidable injury and a decline in psychosocial well-being.
Failure to Report Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of abuse and injuries of unknown origin to the State Survey Agency (SA) and Adult Protective Services (APS) for two residents. Resident 25, a male with dementia and other health issues, was found with bruising on his right hand by his family member, who reported it to the facility. The facility initially classified the injury as of unknown origin but later determined it to be of known origin without reporting it to the SA or APS. Additionally, previous injuries to Resident 25, including bruises on his nose and hip, were not reported to APS, although the hip injury was reported to the SA. The Assistant Director of Nursing and the Director of Infection Control confirmed that the facility did not report the recent injuries of Resident 25 to the appropriate agencies. The Assistant Administrator acknowledged that the bruising on Resident 25's nose and hand should have been reported as injuries of unknown origin. The facility's policy requires immediate reporting of such allegations to the SA and other agencies, but this was not adhered to in these cases. For another resident, Resident 209, an allegation of abuse was reported to the SA but not to APS. The Assistant Administrator admitted to being unaware of the obligation to report the event to APS. The facility's policy mandates reporting any reasonable suspicion of crime against residents to the SA and law enforcement within prescribed timeframes, but this was not followed, leading to a deficiency in reporting obligations.
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A resident with multiple chronic conditions and documented wandering and exit-seeking behaviors repeatedly expressed a desire to go home and was frequently observed near exit doors, yet her care plan did not address elopement risk despite an elopement risk score above the facility’s threshold. She was taken outside and left alone by an activity aide and later observed alone in an unauthorized outdoor area, and subsequently eloped twice through the unsecured main entrance, being found in the parking lot on both occasions only after another resident alerted staff. The main entrance lacked alarms or automatic locking, there was no reception area to monitor egress, behavior monitoring records did not reflect increased supervision after the incidents, and documentation often indicated no behaviors despite prior notes of exit-seeking.
The facility failed to provide adequate supervision and fall prevention for multiple high‑risk residents, resulting in unwitnessed falls and serious injuries. One resident with a history of repeated unwitnessed falls and documented weakness fell in the bathroom while adjusting clothing and using a FWW, sustaining head abrasions and hematomas; he was discovered by housekeeping staff after calling for help, and an RN later stated he needed more supervision. Another resident with dysphagia, prior falls, and declining mobility attempted to stand from a newly issued wheelchair while a CNA was behind a closed curtain assisting another resident, fell forward onto her face, and suffered a scalp laceration, facial contusions, and facial fractures. A third resident with prior falls and on sedating, hypotension‑associated psychotropic and antidepressant medications was placed in a dining area but left unsupervised when nursing staff were called away; she attempted to ambulate to the bathroom without her walker, fell, and sustained a right hip fracture. Her care plan had not been updated to reflect her current need for consistent walker use, and staff did not fully follow existing interventions regarding walker availability and use.
A resident with debility, legal blindness, CHF, DM, medication side effects, and a history of falls had a care plan identifying fall risk and requiring standby assist with ambulation. Despite this, staff left the resident unsupervised while the RN walked away and the CNA was busy with another resident, and the resident attempted to ambulate without a walker, leading to an unwitnessed fall and hip fracture. The care plan had not been fully updated to reflect the need for consistent walker use, and staff did not fully follow existing interventions related to walker availability and use.
Surveyors identified multiple infection control failures, including two residents with indwelling urinary catheters whose drainage tubing was observed lying on the floor, with one resident’s tubing visibly discolored and containing sediment and associated complaints of itching and leakage. Nursing staff acknowledged the tubing should not be on the floor and that the soiled tubing should have been addressed, while a CNA performed catheter care for a resident on Enhanced Barrier Precautions wearing only gloves and no gown, with PPE stored down the hall rather than immediately outside the room as required by facility policy. The facility’s Legionella water management plan, which called for high hot-water setpoints, routine temperature monitoring, flushing, and review of logs, was not being implemented, with only lower temperature logs available and the new IP reporting no active control measures or collaboration with maintenance. In addition, trash bags were repeatedly left piled outside the trash bin and on an exterior stairwell landing, with housekeeping staff relying on a maintenance worker with the only key to the bin and reporting delays in trash being placed inside, resulting in obstructed access and unsanitary trash accumulation.
Staff failed to timely report a large, dark bruise of unknown origin on a resident’s left hip and thigh. A CNA first observed the bruise during a night shift but did not notify the nurse on duty and only relayed the information to an incoming CNA. Later, a CNA, an RNA, and an RN observed and discussed the bruise during care, and the RN assessed it but assumed it had already been reported and did not document an initial entry or initiate required notifications. The RNA later noted another large bruise and informed an LPN. Despite multiple staff being aware of the injury, the DON, Administrator, physician, resident representative, and State Agency were not notified within the required 2-hour timeframe specified in the facility’s abuse and injury-of-unknown-source reporting policy.
Nursing staff failed to perform and document timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. A CNA first observed the bruise and did not report it to a nurse, only relaying it to another CNA, and when an RN later assessed the bruise, the RN assumed it had already been reported and did not complete an initial assessment entry. An LPN subsequently noted the large purplish bruise, found no prior documentation, and initiated an event, while weekly skin assessments by an RN repeatedly documented no new skin impairments and omitted the bruise. Nursing notes recorded that the bruise was visible and then fading over time, but lacked complete assessment details such as size, shape, and full description, and the incorrect event form was used, resulting in incomplete documentation of the injury.
A resident with multiple comorbidities, including ESRD on dialysis, developed urinary retention during a rehab stay and was discharged home with an indwelling Foley catheter and a mechanical lift. The resident’s son, designated as caregiver, had previously assisted her at home but had not managed a urinary catheter before. Nursing documentation at discharge noted follow-up with a PCP and home health and described the transfer to the son’s car, but recorded education/training as not applicable and contained no evidence of Foley catheter care teaching. During interviews, staff indicated that a vendor trains caregivers on the mechanical lift but could not confirm any nursing education on catheter care, and the Administrator acknowledged nursing’s responsibility to assess, provide, and document caregiver training and capacity, which was not done in this case.
A resident with a history of stroke, encephalopathy, gait abnormalities, incontinence, and insulin-dependent Type 2 DM was discharged home alone with only a private hire caregiver for two hours per day, despite provider orders for 24-hour care and therapy recommendations for 24/7 or extensive caregiver support. Interdisciplinary documentation inaccurately indicated the resident had family and a wife as primary caregiver, and there was no evidence that the facility discussed with the resident his limitations, the risks of minimal supervision, or that the provider was informed of the reduced supervision at discharge. The discharge MDS documented full continence despite multiple recorded episodes of incontinence, and the facility did not verify or document that the resident could self-inject insulin or that a qualified caregiver was trained to do so. Additionally, an ordered stool culture for persistent diarrhea was not completed due to improper specimen handling, and there was no documentation that the provider, PMD, or resident was notified that the test was not performed.
Surveyors found that the facility failed to include ordered O2 therapy in a resident’s care plan despite physician orders for continuous O2 via NC with parameters for use and weaning, and the ADON confirmed this omission. In a separate case, a resident with BLE edema and cellulitis was repeatedly observed in bed with exposed legs and no heel protectors in place, even though there were physician orders for bilateral heel protectors and a care plan directive to offload the heels while in bed; nursing staff acknowledged the heel protectors should have been reapplied after PT and a shower.
Two residents were not adequately protected from accidents when one sustained a skin tear during Hoyer lift transfers despite known fragile skin and prior family complaints about staff moving too quickly, and another, identified as high fall risk due to dementia and prior lumbar fractures, was left unsupervised in a hallway in a w/c for a meal after the CNA watching her went to assist another resident, resulting in a fall discovered by a visitor.
Failure to Supervise and Implement Elopement Interventions for an At-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area free from accident hazards and to provide adequate supervision and interventions to prevent accidents, resulting in two elopement incidents involving Resident 36. The resident was an adult female with multiple medical diagnoses including DMII, adjustment disorder with mixed anxiety and depressed mood, hypertension, chronic kidney disease, hypothyroidism, and obstructive sleep apnea. Review of the electronic health record showed numerous progress notes from October 2025 through January 18, 2026 documenting that the resident frequently verbalized wanting to go home, made frequent phone calls to family, asked staff and other residents to take her home, wandered in the facility, and displayed exit-seeking behavior, including ambulating near the facility entrance and exit doors. Despite these documented behaviors, there was no care plan addressing her wandering and exit-seeking prior to the first elopement on January 19, 2026. On January 19, 2026, the resident eloped through the main exit doors at approximately 6:10 PM. Earlier that day, around 4:00 PM, an activity aide had taken her for a stroll outside and left her alone sitting at a table outside, and later that same day the DON and a Resident Care Manager observed her sitting alone at the resident smoking tent, where she was not allowed to be. The facility’s Elopement Risk Evaluation had been completed on October 16, 2025 with a score of 0 and again on October 28, 2025 with a score of 2, which met the facility’s threshold for being at risk for elopement (score of 1 or greater). However, the Administrator stated that although they review changes in score to determine needed interventions, no interventions regarding the resident’s elopement risk were implemented prior to the January 19 incident. The DON confirmed that the resident had exit-seeking behaviors prior to the first elopement and that she was functionally at supervision level and able to ambulate with a front-wheeled walker. A second elopement occurred on January 28, 2026 at 4:10 PM, nine days after the first incident. For both elopements, the resident was found in the parking lot near the first handicap stall, and staff were not aware she had left the building until another resident notified them. During the survey entrance on March 11, 2026 at 6:45 AM, the surveyor observed that the main entrance doors were unlocked, lacked an alarm or automatic locking mechanism, and opened into a large open area with no reception or receiving area, with no indication that the door could secure automatically to prevent elopement. Review of Behavior Monitoring and Interventions Reports from January 1 to February 28, 2026 showed documentation only once per shift and did not reflect increased monitoring after the two elopements; most entries were marked “No Behaviors Observed,” which was inconsistent with the exit-seeking episodes documented in the progress notes. The facility could not provide documentation of increased monitoring after the first elopement, and at the time of the Administrator’s interview there was still another resident identified as an elopement risk.
Failure to Provide Adequate Supervision and Fall Prevention for High‑Risk Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure an environment free from accident hazards and to provide supervision based on individual residents’ assessed needs. One resident with a history of multiple unwitnessed falls was observed with a bandage on his head and later with visible bruising and abrasions after an unwitnessed bathroom fall. His care plan documented several prior falls, including unwitnessed falls with head pain, bruising, and sliding out of bed while reaching for a urinal. On the date of the most recent fall, he was found on the bathroom floor on his right side with his pants and underwear around his thighs, reporting that he had been attempting to adjust his clothing while walking with a front‑wheeled walker. He sustained multiple abrasions and hematomas to the top and sides of his head, reported 8/10 head pain and nausea, and required transfer to the ER. Nursing staff reported that a housekeeper, not direct care staff, discovered him after hearing him call for help, and the RN stated that the resident needed more supervision, especially given increased weakness since his prior fall. Another resident with dysphagia, a history of falling, and generalized muscle weakness experienced a fall with major injury after attempting to stand from a newly issued wheelchair. She reported that she stood up and did not expect the wheelchair to be so high, lost her balance, and fell forward onto her face while the CNA was in the same room but behind a closed curtain assisting another resident. The resident sustained an approximately two‑inch actively bleeding scalp laceration, facial contusions, and later ER documentation confirmed a closed fracture of the left maxillary sinus, a closed fracture of the left orbital floor, a scalp laceration, and a closed head injury. The MDS showed that, prior to this fall, she had already demonstrated decline in eight of ten mobility areas, and she later returned from the hospital with 8 staples in her scalp and extensive bruising and swelling to the left eye, scalp, and ear. The resident and her family member expressed that the fall should not have happened and attributed it to short staffing. A third resident with a documented fall history and on medications including quetiapine and mirtazapine, both of which have side effects of drowsiness, dizziness, and orthostatic hypotension, sustained an unwitnessed fall resulting in a right hip fracture. She was found on the floor on her right side without shoes, socks, or her walker, and stated she had been trying to go to the bathroom. The care plan had not been updated to fully reflect her current needs for consistent walker use, and staff did not fully adhere to existing interventions regarding walker availability and use at the time of the incident. Nursing staff interviews indicated that this resident required line‑of‑sight supervision and “eyes on her” because she would suddenly stand without warning and was unsteady, yet at the time of the fall she had been placed in the dining area in front of the nurse’s station and was left unsupervised when the RN and CNA were called away. Kitchen staff later found her on the floor, and she reported being on the floor for about 15 minutes before help arrived. She was diagnosed with a right hip fracture, underwent surgery, was admitted to the ICU for hypotension, and subsequently died; the unwitnessed fall with hip fracture was determined to be a contributing event that exacerbated her overall medical decline, though not the primary cause of death.
Failure to Implement Standby Assist and Walker Use Care Plan Resulting in Fall Injury
Penalty
Summary
The facility failed to implement a person-centered intervention for standby assistance with ambulation as outlined in the comprehensive care plan for one resident, resulting in an unwitnessed fall with major injury. The resident had multiple risk factors for falls, including debility, legal blindness, congestive heart failure, diabetes mellitus, medication side effects, and a history of prior falls. The care plan, revised on 01/23/2026, identified the resident as at risk for falls and included an intervention for standby assist with ambulation, updated on 01/22/2026, with a goal that the resident would be free of falls through the review date of 03/25/26. Prior to the incident, the resident had experienced two falls in the facility, one witnessed fall onto the buttocks while fixing clothing by a mirror and one guided fall after losing balance while walking. On 02/06/26, the resident sustained an unwitnessed fall in building 1 on the B unit while attempting unsupervised ambulation without her walker, resulting in a right hip fracture and transfer to the ER for evaluation and surgery. Interviews with nursing staff confirmed that the resident was known to suddenly stand without warning, was unsteady, and required someone present when walking, and that she needed continuous visual supervision due to her fall risk. At the time of the fall, the RN reported having to walk away and the CNA was occupied with another resident, leaving no one available to assist the resident to get up. The final investigation summary noted that the care plan had not been updated to fully reflect the resident’s current needs for consistent walker use and that staff did not fully adhere to existing care plan interventions regarding the availability and use of the walker at the time of the incident.
Inadequate Infection Control in Catheter Care, Water Management, and Waste Handling
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices, particularly related to urinary catheter care, use of personal protective equipment (PPE), implementation of a water management plan for Legionella, and timely trash disposal. For one resident with an indwelling urinary catheter, the surveyor observed the catheter bag on the floor inside a gray bin with the catheter tubing extending out of the bin and in direct contact with the floor. The tubing showed visible discoloration and white sediment. The resident later reported itchiness outside the vagina and leaking from the catheter. A registered nurse acknowledged awareness of the sediment, stated the catheter was changed monthly, and indicated she planned to contact the physician for more frequent changes. She also stated the tubing could be irrigated with saline and confirmed that catheter tubing should not be on the floor for infection control reasons. The Infection Preventionist (IP), when shown a photograph of the tubing on the floor with sediment, confirmed the tubing should have been changed and that tubing should not be on the floor due to infection risk. Another resident, a male with a history of stroke and benign prostatic hyperplasia requiring an indwelling urinary catheter, was on Enhanced Barrier Precautions (EBP) with orders for catheter care every shift and as needed. During observation, his catheter tubing was seen lying directly on the floor when the bed was in the lowest position. The nurse present acknowledged that the tubing should not be on the floor and adjusted the bed and tubing placement. In a separate observation, a CNA performed catheter care for this resident, including emptying the catheter bag and cleaning the lower catheter tubing and the floor area near the bag, while only wearing gloves and no gown, despite a noticeable urine-like odor at the bedside. The IP confirmed that the resident was on EBP due to having a Foley catheter and stated staff should wear PPE, including a gown, when performing catheter care such as emptying the collection bag in case of splashes. The CNA acknowledged she was supposed to wear PPE for catheter care and indicated PPE was stored down the hall on a wall shelf, not immediately near or outside the resident’s room, despite the facility’s EBP policy stating gowns and gloves should be made available immediately near or outside the room for high-contact care activities such as urinary catheter care. The facility also failed to effectively implement its water management plan for Legionella prevention and control. The written plan described a central hot water system with recirculation, specified hot water storage tank setpoints at or above 140°F and distribution temperatures above 124°F, and listed monitoring procedures including monthly hot water temperature checks by maintenance, as well as verification and validation steps such as reviewing monitoring logs, infection surveillance data, and water testing results. However, the Maintenance Director reported there were no storage or water heater tanks with water temperatures greater than 140°F, and only one month of temperature logs was available, showing resident room and water heater temperatures between 105°F and 115°F, which did not align with the Legionella prevention temperature guidelines referenced from CDC. The IP, newly in the role, stated she was not familiar with the water management plan, that collaboration with maintenance was non-existent, and that no control measures, weekly flushing of shower heads and faucets, or monthly temperature monitoring were being done. Additionally, the facility did not ensure prompt disposal of trash, resulting in trash bags being piled outside the trash bin and on an exterior stairwell landing. Surveyors observed multiple trash bags outside the facility next to the trash bin and on the stairwell landing, blocking access to the staircase. Housekeeping staff reported that trash from the second floor was placed in the bin about every hour but sometimes had to wait for the maintenance worker, who had the only key to open the bin. Another housekeeper stated she left heavy trash bags by the bin twice a day because she could not lift them into the bin and relied on the maintenance worker to place them inside, noting she had notified him about trash needing to be placed in the bin about an hour earlier. The maintenance worker stated he had been told by aides to hold off putting trash in the bin but did not know why. The Maintenance Director later confirmed that housekeepers should be putting trash in the bin more frequently and acknowledged that trash pile-up can lead to unsanitary conditions affecting the facility and neighborhood. Overall, these observations and interviews show that the facility did not maintain catheter tubing off the floor or address visibly soiled tubing, did not consistently use required PPE for residents on EBP during high-contact catheter care, did not implement or monitor its Legionella water management plan as written, and did not ensure timely placement of trash into secured bins, resulting in accumulated trash in exterior areas.
Failure to Timely Report Injury of Unknown Source Resulting in Serious Bodily Injury
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown source that resulted in serious bodily injury for one resident. Staff first observed a large, dark bruise on the resident’s left hip and thigh around midnight during a night shift, but the CNA who discovered it did not notify the night shift nurse, stating she was busy and forgot, and instead only told an incoming day shift CNA. The day shift CNA later informed the RN on duty while assisting with the resident’s care. The RN assessed the bruise, describing it as purple and located on the posterior left thigh; the resident did not recall how it occurred and denied pain or discomfort. The RN assumed the bruise had already been reported to licensed staff on the prior shift and did not make an initial entry or initiate required notifications. Subsequently, the restorative nurse aide (RNA) and another CNA observed the large bruise in the lower hip area while assisting with a shower and confirmed with each other that the on-duty RN had been informed. The next day, the RNA observed another large bruise on the resident’s thigh and reported it to an LPN. Despite multiple staff being aware of the bruising over more than one shift, the DON, Administrator, physician, resident representative, and State Agency were not notified until several days after the bruise was first seen. This sequence of inaction and miscommunication occurred despite the facility’s abuse policy requiring that allegations involving abuse, neglect, exploitation, mistreatment, and injuries of unknown source that result in serious bodily injury be reported immediately, but no later than two hours after the allegation is made, with immediate notification of the Administrator or designee to initiate reporting to state agencies.
Failure to Perform and Document Complete Skin Assessment for Large Hip/Thigh Bruise
Penalty
Summary
The facility failed to ensure licensed nursing staff demonstrated appropriate competencies and skills to perform timely, thorough, and accurate skin assessments for a resident with a large bruise on the left hip and thigh. Staff first observed the bruise on 07/30/25, but no initial assessment was conducted at that time. A CNA working the night shift observed the bruise and did not report it to the Charge Nurse, instead only telling the incoming day shift CNA the next day. The day shift CNA then informed an RN, who assessed the bruise as purple in color on the posterior left thigh, with the resident unable to recall how it occurred and denying pain or discomfort. The RN assumed the bruise had already been reported to licensed staff and did not complete an initial assessment entry. On 08/01/25, an LPN observed the large purplish bruise extending from the resident’s lower hip to the thigh, found no prior assessment or event note documenting the bruise, and then created an event and notified the DON. An X-ray ordered by the physician showed soft tissue swelling without acute fracture, dislocation, or bony lesions. Despite the presence of the bruise, weekly skin assessments completed by the RN on 07/31/25, 08/07/25, 08/14/25, 08/21/25, and 08/28/25 did not document the bruise on the left hip and thigh. These assessments repeatedly documented that there were no new onset skin impairments and described only dry scattered scabs to the bilateral shins treated with Medihoney gel. Nursing notes associated with the event report initiated on 08/01/25 documented that the bruise on the left hip and thigh was visible and then fading over multiple subsequent dates, with color changes from purple to yellow. However, these notes did not include a complete skin assessment or detailed documentation of the bruise’s progression, such as size, shape, initial appearance, or date of resolution. During interviews, the IP and Administrator confirmed that the RN’s weekly skin assessments should have included the bruise, that staff should perform a full skin assessment and initiate an RMC Injury/Integumentary Alteration event when a new skin issue is identified, and that the event report used by the LPN was not the correct form and did not capture a complete assessment. The report also cross-referenced F609, noting that the injury of unknown source resulting in serious bodily injury was not reported to the Administrator within two hours of discovery, as it was first observed on 07/30/25 but not reported until 08/01/25.
Failure to Assess and Educate Caregiver on Foley Catheter Care Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an adequate discharge plan and caregiver education for a resident who was discharged home with an indwelling urinary catheter. The resident, an older female admitted for short-term rehabilitation after an acute hospitalization, had multiple medical conditions including diabetes, spinal stenosis, chronic back pain, muscle weakness, gait and mobility abnormalities, and end-stage renal disease requiring dialysis. While in the facility, she developed urinary retention and required an indwelling urinary catheter, which remained in place at the time of discharge home with her son as the designated caregiver. The nursing progress note documented that the resident was discharged home with her son, to be followed by her primary care provider and home health services, and that staff assisted with transfer to the son’s car. The note also indicated “Education/Training Response as indicated: n/a,” and there was no documentation that the caregiver received education on Foley catheter care. Following a report of concern to the Office of Health Care Assurance that the resident did not have needed resources after discharge and that the caregiver could not safely manage the urinary catheter, surveyors reviewed records and interviewed staff. The Social Services Assistant, after consulting the Social Worker, reported that a vendor provides caregiver training on the mechanical lift when delivering the equipment to the home, but the Social Worker did not know if nursing had provided catheter care education. It was acknowledged that although the son had cared for the resident prior to hospitalization, she did not have a urinary catheter at home before this admission. In an interview, the Administrator confirmed that nursing was responsible for assessing caregiver training needs, providing and documenting the training, and documenting that the caregiver was willing, capable, and had the capacity to provide the required care. The facility was unable to provide evidence that such assessment and education on Foley catheter care were completed or documented for this caregiver.
Failure to Ensure Safe Discharge Planning and Follow-Up for a Resident Discharged Home Alone
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s transfer/discharge plan met his needs and preferences and that he was adequately prepared and supported for a safe discharge to the community. The resident was an older male admitted after a stroke for medical management and rehabilitation, with a history of encephalopathy, muscle weakness, gait and mobility abnormalities, Type 2 DM on insulin, chronic heel ulcers, and hypertension. While in the facility, he was incontinent of bladder and bowel and wore disposable briefs. Prior to the stroke, he lived alone with community supports including a care coordinator, meals on wheels, transportation, a life alert system, help from a neighbor with groceries, and a friend who cleaned his house. He did not have a power of attorney. During the stay, an interdisciplinary care conference note documented that the resident would be discharged “home with family,” that he lived alone but had community services and a health coordinator, and that he would return home with established services and home health PT/OT/nursing. The discharge planning section inaccurately indicated that he had family and identified a wife as the primary caregiver, and it documented an intervention to evaluate and discuss prognosis, limitations, risks, benefits, and needs for independence. However, the resident did not have a wife or family caregiver, and the private hire caregiver was arranged by the facility. There was no evidence that the facility discussed with the resident the prognosis for independent living with minimal supervision, his limitations, or that he fully understood the risks. There was also no evidence that the provider was aware that the final discharge arrangement would involve only minimal supervision rather than the ordered level of care. The resident’s discharge orders specified a need for 24-hour care and home health services including PT, OT, speech therapy, nursing, and medication management, and therapy documentation indicated he was not safe to be home alone and required increased assistance at home. PT and OT notes recommended 24/7 care or at least a caregiver for 20 hours per week, and the resident’s modified Barthel ADL score reflected moderate dependence. The discharge MDS showed he required partial/moderate assistance for several ADLs and supervision or touching assistance for transfers and mobility, but it documented him as always continent despite nursing documentation of multiple episodes of urinary and bowel incontinence in the week prior to discharge. The social services assistant confirmed the resident had no family or full-time caregiver, knew there would be a lag before community services resumed, and arranged a private hire caregiver for only two hours per day without knowing the caregiver’s qualifications. She acknowledged that the resident needed to be checked on daily and that he required daily insulin injections, which she stated nursing was responsible to ensure could be safely managed, but the facility could not provide evidence that the resident was competent to self-inject insulin or that a capable caregiver was identified and trained. Additional documentation and interviews showed that the care coordinator had informed the social services assistant that the resident had no support at home and that community services such as meals on wheels would not resume immediately, and that home health evaluation and possible services would not start until several days after discharge. The social services assistant did not document her discharge planning communications with the care coordinator in the medical record at the time and later produced a retrospective typed note. The friend who cleaned the resident’s home reported that upon discharge he struggled to get out of a chair, walked slowly, had frequent accidents on the floor, and could not figure out how to set his insulin pen correctly. The PT and OT confirmed that the resident had memory issues, was not at his pre-stroke baseline, could not change his own brief, and still needed assistance and cues for toileting and hygiene. The DON stated that nursing was responsible to ensure the resident could self-inject insulin or that a trained caregiver was identified, and confirmed the facility lacked evidence of such competence or caregiver training. The deficiency also included a failure to ensure appropriate follow-up for an ordered diagnostic test prior to discharge. Nursing documentation showed the resident had persistent diarrhea and stomach upset, and a stool culture and O&P were ordered along with a probiotic. The laboratory later reported that the stool sample was received in a sterile container instead of stool media, was no longer stable for testing, and that the resident was no longer at the facility so recollection was not needed. There was no documentation that the provider, primary medical doctor, or resident was notified that the stool culture was not completed. The DON confirmed that the stool culture and sensitivity had not been done and that the provider should have been notified to ensure follow-up after discharge.
Failure to Care Plan O2 Therapy and Implement Heel Protector Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans that addressed all ordered treatments. For one resident receiving oxygen (O2) therapy, surveyors observed the resident on 1 L O2 via nasal cannula and later without O2, with no signs of respiratory distress. Record review showed a physician’s order for continuous O2 supplementation at 1–4 L/min via nasal cannula for shortness of breath or SpO2 < 90%, with an order to wean O2 as tolerated every shift. However, the resident’s care plan did not include any problems, goals, or interventions related to O2 therapy. The ADON confirmed that O2 therapy was not included in the care plan and acknowledged that the care plan is important as it directs the care provided. The facility’s Oxygen Administration policy stated that the resident’s care plan will identify the interventions of oxygen therapy based on assessment and orders. A second deficiency involved failure to implement the care plan intervention for bilateral heel protectors for a resident with bilateral lower extremity (BLE) edema and cellulitis. The resident was repeatedly observed in bed with BLE edema, redness, and dry, scaly skin, with BLE exposed and no socks or heel protectors applied, despite reporting pain at 8/10 and stating that pain medication and daily cream application provided relief. Record review showed a physician’s order for bilateral heel protectors and a care plan intervention to ensure heels are offloaded by floating heels while in bed. Nursing staff confirmed that heel protectors should have been reapplied after physical therapy and a shower to protect the resident from further skin breakdown. The facility’s Comprehensive Care Plan policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ medical and nursing needs identified in the comprehensive assessment.
Failure to Prevent Injury During Mechanical Transfer and Unsupervised Hallway Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and injuries during transfers and while residents were out of bed. One resident with dementia, hemiplegia following a stroke, and fragile skin experienced recurrent skin tears associated with transfers using a Hoyer lift. Family members reported that staff needed to be more careful when using the lift because the resident’s skin tears easily and that problems with skin tears occurred during transfers. The resident was observed wearing Geri sleeves on both arms, and a nursing progress note documented a skin tear to the left elbow that occurred after transferring the resident back to bed. Family members had previously filed a grievance stating that a CNA was moving too fast during a transfer from bed to wheelchair, and that the CNA reported she was holding the Hoyer sling to help navigate the resident’s position during the transfer. The resident’s RN stated that CNAs follow an ADL schedule, that the resident receives showers four times per week, and that Geri sleeves are used as a preventive measure. The RN also stated that the resident often screams during Hoyer transfers and characterized this as the resident’s behavior. The DON reported that various considerations had been made for the resident at the family’s request, including an increased shower schedule and discussion about nail trimming, while confirming that the family declined staff trimming the resident’s nails. A second resident, an older female with dementia, debility, pain, and a history of lumbar fractures, was care planned as being at risk for falls, with an approach to observe her frequently and place her in a supervised area when out of bed. Despite this, she was placed in a hallway in a wheelchair for a meal and left unattended when the CNA who had been watching her went to assist another resident in a room. The charge nurse was in the Resident Care Manager’s office when a visitor alerted staff that the resident had fallen; the resident was found on the floor on her left side. The charge nurse later acknowledged that the resident was at high risk for falls due to dementia, should not have been left unsupervised, and that the CNA, a part-time staff member unfamiliar with the residents on that floor, should have called for help before leaving the hallway and losing sight of the resident and others.
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