Northstar Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Carson City, Nevada.
- Location
- 2898 Highway 50 East, Carson City, Nevada 89701
- CMS Provider Number
- 295023
- Inspections on file
- 33
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at Northstar Post Acute during CMS and state inspections, most recent first.
The facility failed to offer a bowel and bladder retraining program for residents assessed as candidates for retraining. Despite having a policy stating that incontinent residents would receive appropriate treatment, the facility did not implement a program until late December 2024. The program lacked a policy, did not assess incontinence types, and did not document voiding patterns, resulting in residents being placed in briefs and only assessed for incontinence on a two-hour check and change schedule.
Expired medications, including Lidocaine patches and IV solution bags, were found in a medication cart and storage room. The ADON confirmed the expiration dates, and the DON stated that expired drugs should be destroyed according to facility policy.
A facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. One resident did not receive Diclofenac Sodium gel due to unavailability, and another received Morphine Sulfate at a concentration not matching the eMAR. The LPN did not seek physician clarification for the discrepancy. The DON emphasized the need for staff to review eMARs and address discrepancies, as per facility policy.
A facility failed to protect resident information and update hospice medication orders in a timely manner. An unattended computer screen displayed resident data, and hospice orders for a resident with prostate cancer were not entered into the EMR. The DON confirmed the expectation for screens to be locked and orders to be updated promptly.
An RN failed to perform hand hygiene during a medication pass, affecting two residents and increasing infection risk. The RN did not wash hands before or after administering medications, adjusting a nasal cannula, or touching residents. The DON confirmed the necessity of hand hygiene as per facility policies.
The facility failed to ensure timely completion of abuse training for three staff members, including a DON, an LPN, and an RN. The training was completed late, contrary to the facility's policy requiring timely training during orientation and annually. This delay had the potential to place residents at risk for abuse and neglect.
The facility did not post current nursing staff information, as required. The posting, dated three days prior, was not updated by the weekend nurse, and the Administrator, who typically updates it in the mornings, had not arrived when surveyors entered the building. This resulted in outdated information being displayed.
A resident did not receive physician-ordered medications on time during the morning medication pass on two consecutive days. The medications were administered late on one day and not at all on the next. An LPN reported being shorthanded, which affected timely medication administration. The DON confirmed the omission and lack of documentation explaining the missed medications, contrary to facility policy.
A resident admitted for orthopedic aftercare following a surgical amputation did not receive the prescribed hydrocodone for severe pain. Instead, the resident was given acetaminophen, which was not effective for the level of pain experienced. The facility's failure to administer the appropriate medication resulted in the resident experiencing severe pain.
The facility failed to develop and implement comprehensive care plans for several residents, including the placement of beds against the wall, the use of bed rails, the administration and monitoring of medications, and the care of urinary catheters and lymphedema. These deficiencies were confirmed by the DON and identified through observations, interviews, and record reviews.
The facility failed to have a policy or process to assess for restraint and risk of entrapment before placing residents' beds against the wall. The DON confirmed that a bed against a wall could be considered a restraint if it restricted movement, and admitted there was no formal process to ensure residents were not restrained upon admission.
The facility failed to ensure communication training was completed by staff for 20 sampled employees, including the Administrator, DON, CNAs, RNs, LPNs, and other staff. Personnel records lacked evidence of the required training, and the Facility Assessment did not document staff completion or a plan for communication training.
The facility failed to ensure the privacy of residents' PHI by leaving computer screens unattended and displaying sensitive information. An LPN and the DON confirmed that the screens should have been locked, and the facility's policies on HIPAA and confidentiality were not followed.
The facility failed to ensure that QAPI training was completed for 11 out of 20 sampled employees, including the Administrator, Registered Dietician, CNAs, Wound Care Nurse, Infection Preventionist, RN, LPNs, Cook, and Housekeeper. The personnel records lacked documented evidence of the required training, as confirmed by the Business Office Manager.
The facility failed to obtain informed consent for the administration of psychoactive medication and for placing resident beds against the wall. A resident was given mirtazapine without consent, and 37 residents had their beds placed against the wall without being informed of the risks or providing consent. The facility's policies on informed consent and restraint use were not followed.
A resident with multiple health issues was unable to reach their call light, which was found draped behind a nightstand. The Executive Director confirmed the call light was not within reach and acknowledged it should always be accessible.
A resident with hemiplegia and hemiparesis requested a room change for more privacy due to cramped conditions and encroaching personal items from roommates. Despite repeated requests and a bed becoming available, the facility failed to move the resident due to poor communication and documentation among staff.
The facility failed to ensure written acknowledgement of the Advance Directive notice was provided to the resident or the resident's representative for three sampled residents. The Executive Director confirmed that the clinical records of these residents did not include signed Advanced Directive Acknowledgements, despite the facility's policy requiring it within 48 hours of admission.
The facility failed to provide a resident with a Notice of Medicare Non-Coverage (NOMNC) prior to discharge. The resident, admitted with acute respiratory failure with hypoxia, did not receive the required notice, as confirmed by the Assistant Social Worker and the Director of Nursing.
The facility failed to provide written notification of transfer or discharge to a resident and their representative. The resident, who had multiple diagnoses including hemiplegia and type II diabetes mellitus, was transferred to an acute care hospital due to abnormal vital signs. The required Notice of Transfer or Discharge form was not completed, and the Director of Nursing confirmed this oversight.
The facility failed to document physician's orders for wound care and dialysis for three residents, leading to improper management of a wound vacuum, missed dialysis treatments, and delayed wound care for a pressure ulcer.
The facility failed to develop baseline care plans for wound care, oxygen therapy, and dialysis for two residents. One resident had issues with a wound vacuum and lacked proper documentation and physician's orders for wound care. Another resident had inconsistencies in oxygen therapy settings and a delayed baseline care plan for dialysis. The facility did not follow its policies on admission and baseline care plans, leading to deficiencies in care.
The facility failed to update the care plan for a resident after discharge from hospice services. Despite the resident's discharge, care plans continued to reference hospice care and were not revised to reflect the change in status. The DON confirmed the oversight, acknowledging that the care plan should have been updated.
The facility failed to provide proper wound care and monitoring for a resident following surgical amputation, did not follow physician orders for pain medication, and the DON did not assist a dependent resident with ADLs. The resident did not receive prescribed hydrocodone for severe pain and was instead given acetaminophen, which was not appropriate for the pain level reported.
The facility failed to ensure the DON provided necessary assistance to a resident with a left below-knee amputation who required help with lower body dressing. During an inspection, the DON did not assist the resident in disrobing, despite the resident's documented need for substantial or maximal assistance.
A resident admitted for orthopedic aftercare following a surgical amputation did not receive appropriate wound treatment due to the absence of physician's orders. The Wound Care Nurse (WCN) and Licensed Practical Nurse (LPN) were unsure about the wound vacuum's functionality and provided wound care without proper documentation or orders. The Director of Nursing (DON) and Executive Director confirmed the lack of necessary physician's orders, which is against the facility's policy.
The facility failed to ensure that a resident with a pressure injury received necessary treatment to prevent deterioration and infection. Despite an initial assessment, the first wound care order was delayed, leading to infection. Additionally, another resident with heel ulcers did not receive wound care per physician orders on multiple occasions, as confirmed by the DON.
The facility failed to have a policy for placing resident beds against the wall and assessing residents for entrapment and safety, affecting 37 of 49 residents. Additionally, a medication was left unsecured in a resident's room, creating a potential accident. The DON confirmed the lack of a formal process for bed placement and physical assessments.
The facility failed to administer oxygen per physician's orders for three residents. One resident with COPD received 2 LPM instead of the ordered 3 LPM, another with acute respiratory failure received 2 LPM instead of 5 LPM, and a third resident had their oxygen flow changed without a corresponding physician's order.
The facility failed to ensure that alternatives were attempted and entrapment risk was assessed before installing bed rails for two residents and a grab bar for one resident. The clinical records lacked necessary documentation, and the facility's policy on bed rail use was not followed.
The facility failed to ensure sufficient Licensed Nurses and CNAs were scheduled for resident care on weekends in July, August, and September 2023. The Staffing Plan projected a 1:12 ratio of CNAs per residents for the day shift and a 1:16 ratio for the night shift, but the facility did not meet these requirements. The Clinical Operations Analyst confirmed that the facility did not report an average census and staffing requirements to CMS, leading to staffing deficiencies.
The facility failed to ensure that physician-ordered medications were available and administered to residents. One resident did not receive senna for constipation, another did not receive ergocalciferol for vitamin D deficiency, and a third did not receive hydrocodone for pain management due to issues with medication availability and administration.
A resident with a diagnosis of encounter for orthopedic aftercare following surgical amputation received acetaminophen for pain levels higher than those specified in the physician's order. The DON confirmed that the medication was not appropriate for the reported pain levels, resulting in unnecessary medication administration.
The facility had a medication error rate of 10%, with three errors out of 30 opportunities. Errors included two residents not receiving their prescribed medications due to unavailability and one resident receiving a medication without a specified dose. The DON confirmed these as medication errors.
A resident admitted for orthopedic aftercare following a surgical amputation did not receive the prescribed hydrocodone for severe pain. Instead, acetaminophen was administered, which was only ordered for mild pain. The resident reported high pain levels and was observed in pain, but the hydrocodone was not given due to pharmacy issues and staff oversight. The facility's medication administration policy was not followed.
The facility failed to ensure the Facility Assessment included staffing requirements based on the average census. The assessment lacked documented evidence for adequate staffing levels, and the Administrator confirmed that staffing plans did not include an average census and staffing levels per shift to meet resident care needs.
A resident's MAR lacked documentation for the administration of an anti-diabetic medication and two antibiotics on multiple occasions. The DON confirmed the discrepancies, which were against the facility's medication administration policy.
The facility failed to accurately report staffing requirements to CMS, resulting in inadequate weekend coverage for residents. The review of CASPER revealed low weekend staffing for July, August, and September 2023. Interviews with staff indicated a lack of training and understanding of PBJ staffing reporting requirements, leading to incomplete and inaccurate submissions.
The facility's QAPI Committee failed to address systemic issues related to beds placed against the walls for 37 residents, implement enhanced barrier precautions for infections, and ensure wound care orders were obtained upon admission. The Executive Director and DON confirmed these deficiencies.
The facility failed to include the Medical Director in the QAPI Committee meetings for the last quarter of 2023. The DON confirmed the absence of the Medical Director in the meetings held in October and November, and no meeting was held in December. The Executive Director cited difficulties in contacting the Medical Director during this period. The facility's QAPI Plan requires the Medical Director's participation.
The facility failed to review and update its Infection Prevention and Control Plan annually and an LPN performed a finger stick/blood sugar test for a resident in the community dining room, violating infection control standards. The glucometer and used lancet were placed on the table without a barrier and the table was not disinfected afterward.
The facility failed to review and update the Antibiotic Stewardship Program (ASP) policy annually, potentially affecting 49 residents. The policy, last reviewed in November 2017, lacked essential components such as processes for trending infections, communicating infection status during transfers, and surveillance outcomes. The DON confirmed the policy was outdated and should have been reviewed annually.
A facility failed to screen a resident for eligibility, provide education, and offer an influenza vaccine for the 2023/2024 season. The resident, with multiple chronic conditions, had requested the vaccine, but it was not administered, and the facility lacked documentation of the required steps.
The facility failed to ensure that a CNA was screened for eligibility to receive a COVID-19 booster vaccine, provided with education regarding the vaccine, and offered the vaccine. The facility did not have the necessary documentation for the CNA, indicating a failure to adhere to its own policy and national standards.
The facility failed to ensure timely completion of resident rights training for two employees. A Registered Dietician and an Infection Preventionist did not complete the required training upon hire, as confirmed by the Business Office Manager. The facility's policy mandates this training for all staff, which was not followed in these instances.
The facility failed to ensure timely completion of elder abuse prevention training for three employees, including a Registered Dietitian, a CNA, and a Laundry Aide. The Human Resources Payroll Clerk confirmed that the required training was not completed as per the facility's policy.
The facility failed to provide timely infection control training to all staff, as required by their infection prevention and control program. Three employees did not complete the training within the mandated timeframe, with delays ranging from one to seven days. The Business Office Manager confirmed the requirement for timely training and acknowledged the delays.
The facility failed to ensure timely compliance and ethics training for five employees, including the DON, Activity Manager, Registered Dietician, CNA, and Housekeeper. The Business Office Manager confirmed the training was required upon hire but was not completed timely for these staff members.
The facility failed to ensure behavioral health training for 7 out of 20 sampled employees, including key staff such as the Executive Director and Infection Preventionist, as required by their training protocols.
The facility failed to provide a homelike environment by frequently using an overhead paging system to communicate with staff, contributing to excessive noise levels. This was observed multiple times across various dates and locations within the facility, contrary to the facility's policy on maintaining comfortable sound levels.
Failure to Implement Bowel and Bladder Retraining Program
Penalty
Summary
The facility failed to offer a bowel and bladder retraining program for residents assessed to be candidates for retraining. This deficiency was identified for 11 out of 49 residents, including those with various medical conditions such as muscle weakness, parkinsonism, Alzheimer's disease, and others. The Minimum Data Set (MDS) assessments for these residents documented varying levels of incontinence, yet no trial of a toileting program was attempted, and no program was in place to manage their incontinence. The Director of Nursing (DON) confirmed that the facility did not have a bowel and bladder program until the week of December 16, 2024. The program that was eventually implemented consisted of scheduled toileting on a two-hour schedule. However, the facility lacked a policy for a bowel and bladder program, did not assess the type of incontinence, and did not document voiding patterns. All residents were placed in briefs unless they refused, and they were only assessed for incontinence and put on a two-hour check and change schedule. The facility's policy on incontinence, dated December 2021, stated that residents who were incontinent of bladder or bowel would receive appropriate treatment to prevent infections and restore continence to the extent possible. Despite this policy, the facility's failure to implement a bowel and bladder retraining program for eligible residents represents a significant oversight in providing appropriate care to maintain and achieve the highest continent status for residents.
Expired Medications Found in Medication Cart and Storage Room
Penalty
Summary
The facility failed to ensure expired medications were removed from a medication cart and a medication storage room, as observed during a survey. During the inspection of the B hall medication cart, a box of Aspercreme Lidocaine patches with an expiration date of 10/2024 was found, which should have been discarded by 10/31/2024. The Assistant Director of Nursing (ADON) confirmed the expiration date and acknowledged that the patches should have been removed and discarded. Additionally, in the B hall medication storage room, two IV solution bags containing Normal Saline with an expiration date of 10/2024 and one IV solution bag containing Dextrose with an expiration date of 11/2024 were found. The ADON confirmed these IV solution bags had expired and should have been discarded. The Director of Nursing (DON) stated that expired drugs were to be destroyed and confirmed that expired medications should be removed from medication carts. The facility's policy required that medications and biologicals not be retained longer than recommended by the manufacturer and that outdated/expired medications be destroyed or returned.
Medication Error Rate Exceeds 5% Due to Omission and Dose Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate. This was identified through observation, interview, clinical record review, and document review. There were 25 medication administration opportunities, and two errors were noted. One error involved a resident who did not receive Diclofenac Sodium gel as it was not available in the facility, leading to a documented omission in the Medication Administration Record (MAR). Another error involved a resident receiving Morphine Sulfate at a different concentration than what was ordered in the electronic Medication Administration Record (eMAR). The first resident was supposed to receive Diclofenac Sodium gel for osteoarthritis, but the medication was marked as not available in the MAR. The second resident was administered Morphine Sulfate at a concentration that matched a hospice provider's order but did not match the eMAR. The Licensed Practical Nurse (LPN) did not contact the physician for clarification before administering the medication. The Director of Nursing (DON) stated that the expectation was for nursing staff to review the eMAR and contact the physician if discrepancies were found. The facility's policy defined medication errors as dose errors and omission errors, which were evident in these cases.
Failure to Safeguard Resident Information and Update Hospice Orders
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain complete medical records in accordance with professional standards. An unattended computer screen on a medication cart displayed resident information, which was confirmed by a Registered Nurse (RN) who acknowledged the screen was unlocked and unattended. The Director of Nursing (DON) stated that the expectation was for computer screens to be locked when not in use, as per the facility's policy to protect resident privacy. Additionally, the facility did not enter hospice medication orders into the electronic medical record (EMR) in a timely manner for a resident diagnosed with malignant neoplasm of the prostate. The resident's hospice communication binder contained a physician order for medications that were not reflected in the EMR. A Licensed Practical Nurse (LPN) confirmed the oversight and acknowledged forgetting to update the EMR with the new orders. The DON explained that hospice orders should be entered into the EMR the same day they are received, as per facility policy.
Failure to Perform Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) performed proper hand hygiene during a medication pass, which had the potential to affect all residents receiving medication from the RN and increased the risk of infection spread. On December 18, 2024, during a medication pass from 8:44 AM to 9:12 AM, the RN administered medications to two residents, adjusted a resident's nasal cannula, touched a resident's shoulder, and donned and doffed gloves without performing hand hygiene at any point. The RN confirmed the lack of hand hygiene before and after medication preparation and administration, as well as after contact with residents and their environment. The Director of Nursing (DON) explained that hand hygiene was required between care of different residents and confirmed that it should be performed after adjusting a resident's nasal cannula, touching a resident, and removing gloves. The facility's policies on Medication Administration and Hand Hygiene, revised in 2023 and 2024 respectively, documented the necessity of hand hygiene before and after administering medications and contact with residents. The failure to adhere to these policies was acknowledged by the RN and DON, highlighting the potential for infection spread due to inadequate hand hygiene practices.
Delayed Abuse Training for Staff
Penalty
Summary
The facility failed to ensure timely completion of initial and annual training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation for three employees. Employee #2, hired as the Director of Nursing, completed the required abuse training one month late. Employee #9, a Licensed Practical Nurse, completed their annual abuse training eight months late. Employee #13, a Registered Nurse, completed their initial abuse training 14 days late. The facility's policy required all new employees to be trained in abuse during orientation and existing staff to receive planned education on abuse. The Payroll Human Resources employee confirmed the delay in training for these employees, which had the potential to place residents at risk for abuse and neglect.
Failure to Post Current Nursing Staff Information
Penalty
Summary
The facility failed to ensure that the current nursing hours were posted daily, as required. On December 16, 2024, at 8:05 AM, the nursing staff posting, located across from the main nursing station, was observed to be dated December 13, 2024. This outdated posting was confirmed by the Director of Nursing (DON) at 9:42 AM, who stated that it was the responsibility of the weekend nurse to update and post the nursing staff and hours during weekends. However, this was not done. Additionally, the Administrator, who usually updated the staff posting in the mornings, had not arrived by the time surveyors entered the building, resulting in the staff posting not being current when surveyors arrived.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that physician-ordered medications were administered to a resident during the morning medication pass on two consecutive days. On 08/01/2024, the medications were administered late, and on 08/02/2024, they were not administered at all. The resident, who had a history of hemiplegia, chronic respiratory failure, and hypertensive heart disease, reported receiving morning medications late. A Licensed Practical Nurse (LPN) confirmed that due to being shorthanded, they often struggled to administer medications on time. The Medication Administration Audit Report showed that several medications scheduled for 7:00 AM and 8:00 AM on 08/01/2024 were administered around 11:00 AM. On 08/02/2024, the Medication Administration Record (MAR) lacked documentation of the administration of the resident's medications, indicating they were not given. The Director of Nursing (DON) confirmed the omission and noted that the resident's clinical record lacked documentation explaining why the medications were not administered. The facility's policy required medications to be administered at the correct time, and the DON confirmed that the medications were not administered within the facility's flex time schedule.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to ensure appropriate pain management for a resident admitted for orthopedic aftercare following a surgical amputation. Resident #403, who had a left foot amputation, reported not receiving the prescribed hydrocodone for severe pain since admission. Instead, the resident was given acetaminophen, which was not effective for the level of pain experienced. The resident's pain levels were consistently high, ranging from six to eight on a scale of one to ten, and the facility did not administer the hydrocodone as ordered by the physician. The Licensed Practical Nurse (LPN) confirmed that the facility was unable to fill the hydrocodone order and that acetaminophen was administered in its place. The Director of Nursing (DON) acknowledged that the hydrocodone was not administered and that the facility had an emergency supply (medbank) that could have been used. The DON also confirmed that the resident's pain levels were not adequately managed with acetaminophen and that the medication administration record (MAR) lacked proper documentation for acetaminophen administration. The facility's pain management policy, dated 11/12/19, stated that pain management should be provided consistent with professional standards of practice. However, the facility did not adhere to this policy, resulting in Resident #403 experiencing severe pain without appropriate medication. The DON admitted that the lack of proper pain assessment and medication administration could lead to psychological harm and other complications for the resident.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to multiple deficiencies. Specifically, the facility did not create care plans for the placement of beds against the wall for 31 out of 49 residents, the use of bed rails for one resident, the administration and monitoring of anticoagulant and diuretic medications for one resident, and the monitoring and care of a urinary catheter and lymphedema for another resident. These omissions were identified through observations, interviews, clinical record reviews, and document reviews conducted by surveyors. For instance, Resident #34's bed was observed to be against the wall with two quarter-size bed rails, but there was no care plan addressing the use of these bed rails. Similarly, Resident #39 had physician orders for anticoagulant and diuretic medications, but the clinical record lacked a care plan for the use and monitoring of these medications. Additionally, Resident #308 had diagnoses of lymphedema and a urinary catheter in place at the time of admission, yet there were no care plans for the monitoring and care of these conditions. The Director of Nursing (DON) confirmed that the facility lacked policies or processes for determining if a bed against the wall restricted movement and acted as a restraint. The DON also acknowledged that care plans should be developed and implemented for all aspects of a resident's care, including the use of medications and the monitoring of specific conditions. The facility's policies on care planning and restraint use were not followed, resulting in the identified deficiencies.
Lack of Policy for Bed Placement Against Wall
Penalty
Summary
The facility failed to demonstrate effective administration by not having a policy or process in place to assess for restraint and risk of entrapment before placing residents' beds against the wall. The Director of Nursing (DON) confirmed that a bed against a wall could be considered a restraint if it restricted the resident's movement, especially if a full bed rail was present on the open side or if the resident had deficits on the open side of the bed. The DON acknowledged that an assessment for risk of entrapment, physician order, care plan, and informed consent were required for the use of physical restraints but admitted that the facility lacked a formal policy or process for this assessment. The DON explained that the current process relied on communication between staff members to ensure residents were not restrained upon admission by being placed in a bed positioned against a wall. However, the DON admitted there was no formal process in place to determine the appropriateness of beds against the wall and bedrails for residents with cognitive disabilities. The facility's policies on bed rails and restraints outlined the need for assessments, physician orders, care plans, and informed consent, but these were not being followed due to the lack of a formal process. The DON's uncertainty about how to determine the appropriateness of bed placement for residents with cognitive disabilities further highlighted the deficiency in the facility's administration and policy implementation.
Failure to Provide Communication Training to Staff
Penalty
Summary
The facility failed to ensure that communication training was completed by staff for 20 of 20 sampled employees. The personnel records of employees, including the Administrator, Director of Nursing, Activity Manager, Registered Dietician, Assistant Social Worker, Dietary Manager, Certified Nursing Assistants, Registered Nurses, Licensed Practical Nurses, Infection Preventionist, Cook, Dietary Aide, and Housekeeper, lacked documented evidence of communication training. This deficiency was identified through personnel record review, interviews, and document review, revealing that none of the sampled employees had completed the required communication training upon hire or as needed. The facility's policy, last updated in December 2022, mandated that all staff take Effective Communications training to demonstrate competency and skills necessary for resident care. The Facility Assessment, last reviewed in January 2024, also lacked documented evidence of staff completing communication training or a plan for such training. The Business Office Manager confirmed that all staff were required to take communication training and acknowledged the necessity of this training for effectively communicating with residents who have communication deficits. However, the records showed that the required training was not provided to the sampled employees.
Failure to Ensure Privacy of Residents' PHI
Penalty
Summary
The facility failed to ensure the privacy of residents' protected health information (PHI) for multiple residents. Specifically, a medication cart located in the facility's lobby had an open computer terminal screen displaying Resident #27's PHI, including the resident's photograph, room number, age, date of birth, vital signs, and a list of medications. This occurred while the computer was left unattended, and a nurse was not present at or near the cart. The Licensed Practical Nurse (LPN) confirmed the computer terminal was left unattended and should have been logged off before walking away. The Administrator also confirmed that staff were expected to lock computer terminals prior to leaving them unattended. Additionally, another incident was observed where a medication cart located at the main entrance to the facility was left unattended with the computer screen displaying PHI for five residents. The LPN approached the cart after approximately one minute and confirmed that the computer screen should have been locked when not attended. The Director of Nursing (DON) also confirmed that leaving resident information exposed was a violation of the Health Insurance Portability and Accountability Act (HIPAA). The facility's policies on HIPAA and confidentiality of personal and medical records were not followed, leading to these deficiencies.
Failure to Ensure QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that Quality Assurance Performance Improvement (QAPI) training was completed for 11 out of 20 sampled employees. These employees included the Administrator, Registered Dietician, Certified Nursing Assistants (CNAs), Wound Care Nurse, Infection Preventionist, Registered Nurse (RN), Licensed Practical Nurses (LPNs), Cook, and Housekeeper. The personnel records for these employees lacked documented evidence of QAPI training, which is required by the facility's policy. The Business Office Manager confirmed that all staff were required to take QAPI training upon hire, but the records showed that this training had not been completed for the specified employees. The facility's policy, last updated in December 2022, mandated that all staff take QAPI training during new hire orientation and annually thereafter. However, the personnel records for the sampled employees did not reflect compliance with this policy. The Business Office Manager acknowledged the deficiency, confirming that the required QAPI training was missing for the identified employees. This lapse in training was identified through interviews and document reviews conducted by the surveyors.
Failure to Obtain Informed Consent for Medications and Bed Placement
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychoactive medication and for the placement of resident beds against the wall. Specifically, Resident #12 was administered mirtazapine for depression without documented informed consent. Additionally, the consent for buspirone HCl did not match the current dosage being administered. The Director of Nursing (DON) confirmed that informed consent was required for both medications and acknowledged the discrepancy in the documentation. The facility's policy on Psychotropic Medication Management mandates that informed consent must be verified prior to the use of psychoactive medications, which was not adhered to in this case. Furthermore, the facility did not obtain informed consent for placing the beds of 37 out of 49 residents against the wall. This included residents with various diagnoses such as dementia, chronic obstructive pulmonary disease, and muscle weakness. The clinical records of these residents lacked documented evidence that they were notified of the risks of restraints and entrapment, and no signed consent was obtained prior to the bed placement. The DON explained that a bed against a wall could be considered a restraint if it restricted the resident's movement, especially in cases where the resident had deficits on the open side of the bed. The facility lacked a policy or process for determining if the bed placement acted as a restraint. The facility's policies on Proper Use of Bed Rails, Resident Rights, and Restraint Policy all emphasize the need for informed consent and proper documentation when using restraints or making significant changes to a resident's environment. Despite these policies, the facility failed to comply, leading to deficiencies in both medication management and resident safety. The DON confirmed that assessments, physician's orders, care plans, and informed consent were required but not obtained in these instances.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure a call light was within reach for one resident. Resident #308, who has multiple diagnoses including a displaced fracture, severe obesity, lymphedema, and chronic kidney disease, was found sitting in a wheelchair in their room. The resident expressed discomfort and the need for padding under their left lower extremity. The call light was observed to be draped across the nightstand and resting behind it, approximately four feet away from the resident, making it impossible for the wheelchair-bound resident to reach it. The Executive Director confirmed the call light was not within reach and acknowledged that it should always be accessible to the resident.
Failure to Honor Resident's Room Change Request
Penalty
Summary
The facility failed to honor a resident's request for a room change, which was first verbalized on 02/12/24. Resident #35, who was diagnosed with hemiplegia and hemiparesis following a cerebral infarction, expressed a desire for a room with more privacy due to feeling cramped and uncomfortable with the current living conditions. The resident's room had three occupants, and personal items from roommates were encroaching on the resident's space, including incontinence briefs in direct line of sight. Despite the resident's repeated requests, the facility did not take appropriate action to address the issue in a timely manner. Interviews with facility staff, including the Admissions Manager, Assistant Social Worker, Licensed Practical Nurse, and Director of Nursing, revealed a lack of communication and follow-through on the room change request. The process for handling such requests was not consistently followed, and Resident #35's request was not documented or communicated effectively. Although a bed became available over the weekend, the resident was not moved as the Director of Nursing had failed to coordinate with social services. The facility's policy on room changes and resident rights was not adhered to, resulting in the resident's continued dissatisfaction and discomfort.
Failure to Provide Advance Directive Acknowledgement
Penalty
Summary
The facility failed to ensure written acknowledgement of the Advance Directive notice was provided to the resident or the resident's representative for three sampled residents. Resident #306, who was admitted with diagnoses including traumatic hemorrhage of the cerebrum and a fall, did not have a signed Advanced Directive Acknowledgement in their clinical record. This was confirmed by the Executive Director. Similarly, Resident #12, admitted with chronic obstructive pulmonary disease and chronic respiratory failure, and Resident #305, admitted with encephalopathy and repeated falls, also lacked signed Advanced Directive Acknowledgements in their clinical records. The Executive Director confirmed these omissions and stated that the expectation was for the form to be signed within 48 hours of admission. The facility's policy, dated November 2016, outlined that an advance directive is a document where a person states their choices for medical treatment and/or designates who would make healthcare decisions for them. The policy also stated that residents and/or their legal healthcare decision-makers should be informed upon admission and periodically about their rights concerning self-determination of preferred intensity of care and the process for creating and implementing advanced healthcare directives. Despite this policy, the facility did not ensure that the required acknowledgements were signed and included in the clinical records of the three residents in question.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure a resident received a Notice of Medicare Non-Coverage (NOMNC) prior to discharge. Resident #55, who was admitted with a diagnosis of acute respiratory failure with hypoxia, did not have documented evidence of receiving a NOMNC before discharge. The Director of Nursing indicated that the social services department was responsible for handling all beneficiary notices. The Assistant Social Worker confirmed that a NOMNC should have been provided no later than two days before the last day of covered services and acknowledged that there was no documented evidence that Resident #55 received the required notice.
Failure to Provide Written Notification of Transfer or Discharge
Penalty
Summary
The facility failed to ensure that Resident #30 and the Resident's Representative received written notification of transfer or discharge. Resident #30, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction, cognitive social or emotional deficit following cerebral infarction, and type II diabetes mellitus with diabetic chronic kidney disease, was transferred to an acute care hospital on 01/14/24 due to abnormal vital signs. The clinical record lacked documented evidence that the required Notice of Transfer or Discharge form was completed, which should have included details such as the effective transfer date, the facility to which the resident was transferred, the reason for the transfer, and instructions for an appeal, among other required information. The Director of Nursing confirmed that the facility used the Notice of Transfer or Discharge form to notify residents and their representatives of transfer circumstances but acknowledged that the form was not completed for Resident #30's transfer. The facility's policy required that the transfer/discharge notice be provided to the resident, the resident's representative, and the Long-Term Care Ombudsman as soon as practicable when an immediate transfer was necessitated by urgent medical needs. However, the facility failed to maintain evidence that the notice was sent to the Ombudsman, as required by their policy.
Failure to Document Physician's Orders for Wound Care and Dialysis
Penalty
Summary
The facility failed to ensure physician's orders for wound care, wound vacuum, and dialysis were transcribed onto the admission orders for three residents. Resident #403, who had a leg amputation and a wound vacuum, did not have a physician's order for wound care documented upon admission. The wound vacuum was blinking orange, indicating a potential issue, but the staff did not have the necessary orders to address it. The wound vacuum was eventually removed without proper documentation or physician's orders, leading to concerns about the resident's wound care management. Resident #404, who had end-stage renal disease and was dependent on dialysis, also did not have the necessary physician's orders documented upon admission. The resident's dialysis schedule and related care instructions were not recorded until a day after the resident's representative informed the facility about the dialysis appointment. This lack of documentation could have led to the resident missing essential dialysis treatments and proper monitoring of the dialysis access site. Resident #2, who had an unstageable pressure ulcer on the right buttock, did not have a wound care order documented until two weeks after admission. The initial assessment and wound care were performed by an external wound care provider, but the facility failed to obtain and document a physician's order for ongoing wound care. This delay in obtaining the necessary orders contributed to the deterioration of the resident's wound condition. The facility's policies on wound treatment management and hemodialysis were not followed, leading to these deficiencies.
Failure to Develop Baseline Care Plans for Wound Care, Oxygen Therapy, and Dialysis
Penalty
Summary
The facility failed to ensure a baseline care plan was developed to address the use of a wound vacuum for one resident and oxygen therapy and dialysis for another resident. Resident #403, who was admitted with a diagnosis of encounter for orthopedic aftercare following surgical amputation, had a wound vacuum for the surgical site. The resident reported issues with the wound vacuum, including a blinking orange light indicating low battery, and the wound vacuum was eventually removed without proper documentation or a physician's order for wound care. The Wound Care Nurse (WCN) admitted to being unsure about the wound vacuum and did not document the wound treatment from 02/12/24, leading to a lack of a baseline care plan for wound care and the wound vacuum in the resident's clinical record. Resident #404, admitted with diagnoses including end-stage renal disease and dependence on renal dialysis, had issues with oxygen therapy and dialysis care plans. The clinical record lacked a baseline care plan to address the resident's use of oxygen therapy at 1 LPM, and there were inconsistencies in the oxygen flow settings observed and documented. Additionally, the baseline care plan for dialysis was not initiated within the required 48 hours of admission, and the clinical record lacked proper documentation for dialysis care. The facility's policies on admission and baseline care plans were not followed, resulting in deficiencies in the care provided to these residents. The Director of Nursing (DON) and other staff members confirmed the lack of proper documentation and baseline care plans for both residents. The DON acknowledged that insufficient wound care could lead to infection and incomplete healing, and the Licensed Practical Nurse (LPN) confirmed that the baseline care plan for dialysis was not initiated timely. The facility's failure to develop and implement baseline care plans within 48 hours of admission for these residents led to deficiencies in their care and treatment.
Failure to Update Care Plan Post-Hospice Discharge
Penalty
Summary
The facility failed to update the care plan for a resident after they were discharged from hospice services. Resident #34, who was admitted with diagnoses including hereditary motor and sensory neuropathy, hyperlipidemia, and muscle weakness, had a physician's order to be admitted to hospice services for an aortic valve disorder. This order was discontinued on 07/20/23. Despite the discharge from hospice, the resident's care plans continued to reference hospice care and were not revised to reflect the change in the resident's status. The care plans, which addressed various aspects of the resident's care such as self-care deficit, hypertension, cognitive function, preferences, risk for falls, mood problems, nutrition, and pain management, all included references to hospice care and had not been updated since the resident's discharge from hospice services. On 02/15/24, the Director of Nursing (DON) confirmed that Resident #34 was no longer on hospice and acknowledged that the care plan should have been revised upon the resident's discharge from hospice. The facility's policy on comprehensive care plans stated that care plans should be individualized and updated as appropriate to reflect the resident's current needs. However, this policy was not followed in the case of Resident #34, resulting in outdated care plans that did not accurately reflect the resident's current care requirements.
Failure to Provide Proper Wound Care, Pain Management, and ADL Assistance
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality of care by admitting a resident for orthopedic aftercare following surgical amputation without wound treatment or monitoring orders. The resident had a wound vacuum that was blinking orange, indicating a potential issue, but there were no physician's orders for wound care or monitoring. The wound vacuum was eventually removed without proper documentation or orders, and the wound care nurse admitted to not contacting the hospital for more information when the issue was first noticed. Additionally, the facility did not follow physician orders for the administration of pain medication. The resident had an order for hydrocodone for severe pain but did not receive the medication due to issues with the pharmacy and staff oversight. Instead, the resident was given acetaminophen, which was not appropriate for the level of pain reported. The lack of proper pain management was confirmed by the Director of Nursing, who acknowledged the failure to administer the prescribed hydrocodone. Furthermore, the Director of Nursing failed to provide necessary assistance to the resident, who was dependent on staff for activities of daily living (ADLs). During an inspection, the DON did not assist the resident in disrobing to check the surgical dressing, despite the resident's documented need for substantial assistance with lower body dressing. This lack of assistance was confirmed by both the Executive Director and a Certified Nursing Assistant, who stated that the resident required help with dressing and undressing.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to ensure the Director of Nursing (DON) provided necessary assistance to a resident dependent on staff for activities of daily living (ADLs). Resident #403, who had a left below-knee amputation and required assistance with lower body dressing, was observed attempting to disrobe without receiving help from the DON. Despite the resident's documented need for substantial or maximal assistance, the DON did not offer to assist the resident in undressing or repositioning during an inspection to check the surgical dressing. Consequently, the resident was unable to disrobe as required for the inspection. The incident was confirmed by the Executive Director, who acknowledged that it would have been appropriate for the DON to assist the resident. Additionally, a Certified Nursing Assistant (CNA) confirmed that Resident #403 required assistance with maneuvering pants over the hips and legs. The facility's policy on Activities of Daily Living (ADLs) mandates that care and services be provided for dressing, which was not adhered to in this instance. The deficiency was cross-referenced with tags F658 and F689.
Failure to Provide Wound Care According to Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident admitted for orthopedic aftercare following a surgical amputation received appropriate wound treatment according to physician's orders. Resident #403, who had a leg amputation and a wound vacuum for the surgical site, reported issues with the wound vacuum, including a blinking orange light indicating a potential problem. The Licensed Practical Nurse (LPN) and the Wound Care Nurse (WCN) were unsure about the wound vacuum's functionality and did not have a physician's order for its use or for wound care. The WCN eventually removed the wound vacuum and provided wound care without a physician's order, which was confirmed by the Director of Nursing (DON) and the Executive Director. The lack of physician's orders for wound care and the wound vacuum was a significant oversight, as confirmed by multiple staff members, including the DON and the WCN, who acknowledged the necessity of such orders for proper wound management. The WCN admitted Resident #403 and noticed the wound vacuum but did not immediately obtain a physician's order for its use or for wound care. The WCN changed the wound vacuum's batteries and later removed it when it malfunctioned, providing alternative wound care without proper documentation or orders. The DON and the Executive Director confirmed that there were no physician's orders for wound care or the wound vacuum, and the DON acknowledged that insufficient wound care could lead to infection and incomplete healing. The facility's policy on wound treatment management requires wound treatments to be provided according to physician orders, and in their absence, the licensed nurse should notify the physician to obtain orders, which was not followed in this case.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with a pressure injury received the necessary treatment to prevent the deterioration and infection of the pressure injury. Resident #2 was admitted with an unstageable pressure ulcer on the right buttock. Despite the initial assessment and wound care treatment performed by Advantage Wound Care on 10/05/23, the first wound care order for the right buttock was not obtained until 10/19/23. This delay in obtaining the wound care order contributed to the deterioration of the wound, which showed signs of infection and required oral antibiotics. The Director of Nursing confirmed that the wound care order should have been obtained upon admission to prevent the wound from deteriorating. Additionally, the facility failed to provide wound care per physician orders for Resident #45, who had unstageable pressure ulcers on both heels. The resident reported that the dressings on the heel wounds were not changed on multiple occasions, as documented in the Treatment Administration Record (TAR). The Director of Nursing confirmed that the wound care was not provided on 02/13/24, 02/05/24, 01/29/24, and 01/22/24, as required by the physician's order. The facility's policy on wound treatment management stated that wound treatments should be provided in accordance with physician orders, including the frequency of dressing changes, which was not adhered to in this case.
Lack of Bed Placement Policy and Medication Security
Penalty
Summary
The facility failed to have a policy or process for placing resident beds against the wall and assessing residents for entrapment and safety before placement for 37 of 49 residents. This lack of assessments posed risks such as potential restraint, entrapment, and/or placement of residents with conditions predisposing them to accidents in beds against the wall. The clinical records of these residents lacked care plans and documented evidence of assessments for entrapment and restraint, indicating a systemic issue characterized by a lack of established processes or policies, ultimately resulting in substandard quality of care. Additionally, the facility failed to ensure medications were not left unsecured in a resident's room by allowing a resident to self-administer a medication and creating a potential accident by leaving a medication unsecured for one of the sampled residents. An LPN confirmed that nurses were not allowed to leave medications unattended and/or for residents to take at a later time, yet a medicine cup containing an antacid tablet was found on a resident's bedside table, accessible to other residents. The Director of Nursing (DON) confirmed that the facility did not have a policy or process in place regarding the placement of resident beds against a wall. The DON acknowledged that placing a resident with the resident's strong side to the wall and weak side to the open side of the bed would be considered a restraint. The DON also confirmed that new residents were admitted to beds positioned against a wall without having a physical assessment completed, and there was no formal process in place to ensure a resident was not restrained upon admission by being placed in a bed positioned against a wall.
Failure to Administer Oxygen Per Physician's Orders
Penalty
Summary
The facility failed to ensure residents with oxygen therapy were administered oxygen per the physician's order for three residents. Resident #12, who had chronic obstructive pulmonary disease (COPD) and was dependent on supplemental oxygen, was observed receiving oxygen at 2 liters per minute (LPM) instead of the ordered 3 LPM. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) who adjusted the flow rate to match the physician's order. Similarly, Resident #355, who had acute respiratory failure with hypoxia and COPD, was found receiving oxygen at 2 LPM instead of the ordered 5 LPM. This was confirmed by a Registered Nurse (RN) who acknowledged the mismatch with the physician's order. Resident #404, who had chronic atrial fibrillation and hypertensive chronic kidney disease, had a physician's order for oxygen at 1 LPM as needed, which was later updated to 2 LPM continuous and 3 LPM as needed for shortness of breath. However, the resident was observed without oxygen connected to the nasal cannula and later receiving oxygen at 3 LPM without a corresponding physician's order. An RN confirmed that the oxygen flow was changed without an order and could not provide proof of physician approval. The facility's policy on oxygen administration required checking the physician's order for liter flow and adjusting it accordingly, which was not followed in these cases.
Failure to Assess Alternatives and Entrapment Risk Before Installing Bed Rails and Grab Bars
Penalty
Summary
The facility failed to ensure that alternatives were attempted and entrapment risk was assessed prior to the installation of bed rails for two residents and a grab bar for one resident. Resident #34 had bed rails installed without documented evidence of a completed assessment, informed consent, or attempts at alternatives. Similarly, Resident #355 had grab bars installed without a documented assessment of entrapment risk or attempts at alternatives, as confirmed by the Director of Nursing and the Director of Rehabilitation. Both residents' clinical records lacked the necessary documentation to support the use of bed rails or grab bars. Resident #21 had a grab bar installed on the right side of the bed without documented evidence that alternatives were attempted prior to the installation. The Health Information Officer and the Director of Nursing confirmed that the clinical record for Resident #21 lacked documentation of attempted alternatives and their failure to meet the resident's needs. The facility's policy on the proper use of bed rails required an evaluation of alternatives and an assessment of entrapment risk, which was not followed in these cases.
Inadequate Weekend Staffing
Penalty
Summary
The facility failed to ensure a sufficient number of Licensed Nurses and Certified Nursing Assistants (CNAs) were scheduled to perform resident care according to the Facility Assessment for both day and night shifts during weekends in July, August, and September of 2023. The Payroll-Based Journal (PBJ) Staffing Data Report from 07/01/23 through 09/30/23 documented excessively low weekend staffing. The facility's Staffing Plan, created in January 2024, projected a 1:12 ratio of CNAs per residents for the day shift and a 1:16 ratio for the night shift. However, the facility did not have a Staffing Plan in place prior to January 2024, and the Administrator was unaware of the average census needed to base staffing requirements. Facility nursing schedules and timesheets revealed multiple instances of inadequate staffing coverage, with fewer CNAs and LPNs than required by the Staffing Plan on specific dates in July, August, and September 2023. The facility's policies, including the Facility Assessment, Payroll Based Journal (PBJ)-Direct Care Hours Reporting, and Nursing Services and Sufficient Staff, were not adhered to, resulting in insufficient staffing to meet resident needs. The Clinical Operations Analyst confirmed that the facility did not report an average census and staffing requirements to CMS, which contributed to the staffing deficiencies. The facility's failure to provide adequate staffing on weekends compromised the ability to ensure resident safety and maintain the highest practicable physical, mental, and psychological well-being of each resident, as required by the facility's policies.
Failure to Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available and administered to residents. Resident #1 did not receive the prescribed senna tablets for constipation on 02/15/24 because the medication was not available in the facility. Similarly, Resident #47 did not receive the prescribed ergocalciferol capsule for vitamin D deficiency on 02/14/24 due to the medication being unavailable. Both instances were documented in the Medication Administration Record (MAR) as 'Medication Not Available' (MN). The Director of Nursing (DON) confirmed these deficiencies and explained the expected protocol for handling unavailable medications, which includes checking the med bank, contacting the pharmacy, notifying the provider, and documenting in the resident's clinical record. However, these steps were not followed in these cases, leading to missed doses of the prescribed medications for the residents involved. Resident #403, who was admitted with a diagnosis of encounter for orthopedic aftercare following surgical amputation, did not receive the prescribed hydrocodone for pain management from 02/10/24 to 02/13/24. The LPN explained that the facility was unable to receive the prescription from the pharmacy due to a missing signature on the order. Despite the physician's order being active, the hydrocodone was not administered, and the MAR lacked documentation for its administration. The DON confirmed that Resident #403 had not received the medication since admission and acknowledged that the LPN had failed to administer the hydrocodone as instructed. The facility's policy on medication administration, which mandates that medications be administered as ordered by the physician, was not adhered to in these cases.
Failure to Administer Pain Medication Per Physician's Order
Penalty
Summary
The facility failed to administer pain medication per the physician's order for Resident #403, resulting in unnecessary medication administration. Resident #403, who was admitted with a diagnosis of encounter for orthopedic aftercare following surgical amputation, reported high levels of pain on multiple occasions. Despite the physician's order specifying acetaminophen for mild pain (levels one through three), the medication was administered when the resident's pain levels were significantly higher, ranging from six to eight on the pain scale. This discrepancy was confirmed by the Director of Nursing (DON), who acknowledged that acetaminophen was not appropriate for the reported pain levels. The Medication Administration Record documented several instances where acetaminophen was given outside the ordered parameters, including on 02/11/24, 02/12/24, and 02/13/24. The facility's policy on medication administration, dated 10/15/2019, required medications to be administered as ordered by the physician. The failure to adhere to this policy resulted in the administration of unnecessary medication to Resident #403, as confirmed by the DON during the interview.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medication was administered with an error rate of less than five percent. There were 30 opportunities and three medication errors, resulting in a medication error rate of 10%. The deficiencies were identified through observation, interview, clinical record review, and document review. Specifically, Resident #1 did not receive the physician-ordered senna due to the medication being unavailable, as documented in the Medication Administration Record (MAR). Similarly, Resident #47 did not receive the physician-ordered ergocalciferol because it was not available in the facility. Both instances were confirmed by the Director of Nursing (DON) as medication errors. Additionally, Resident #31 received a dose of vitamin D3 without a specified dose in the physician's order. The Licensed Practical Nurse (LPN) administering the medication did not follow the protocol to clarify the dose with the physician, which was confirmed by the DON. The facility's policies on medication administration and medication orders were not adhered to, as they require verification of medication details and clarification of incomplete orders. These actions and inactions led to the identified deficiencies.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure that a resident admitted for orthopedic aftercare following a surgical amputation received the physician-ordered medication for significant pain. Resident #403, who was admitted on 02/10/24, did not receive hydrocodone as prescribed for severe pain levels. Instead, the resident was administered acetaminophen, which was only ordered for mild pain. The resident reported high pain levels and was observed grimacing in pain on multiple occasions, yet the hydrocodone was not administered due to issues with the pharmacy and staff oversight. The Medication Administration Record (MAR) showed that acetaminophen was given when the resident's pain levels were higher than the ordered parameters. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the hydrocodone was not administered as required. The DON acknowledged that the resident's pain management was inadequate and that the hydrocodone order was not fulfilled due to a pharmacy issue and an oversight by the LPN. The facility's policy on medication administration, which mandates that medications be administered as ordered by the physician, was not followed.
Inadequate Staffing Levels in Facility Assessment
Penalty
Summary
The facility failed to ensure the Facility Assessment included staffing requirements based on the average census of the facility. The Facility Assessment dated [DATE] lacked documented evidence for adequate staffing levels related to the average census. On 02/15/24 at 9:41 AM, the Administrator confirmed that the Facility Assessment staffing plans did not include an average census and staffing levels per shift to meet the care needs of each resident. The facility policy titled Facility Assessment, implemented on 10/25/20, documented that the facility assessment would include, at a minimum, the facility's resident populations, staffing needs, physical resources, and risk assessments.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to complete Medication Administration Records (MAR) for the administration of an anti-diabetic medication and two antibiotic medications for one resident. Resident #21, who was admitted with multiple diagnoses including Alzheimer's Disease, bi-polar disorder, major depressive disorder, chronic kidney disease, and type II diabetes mellitus with diabetic neuropathy, had several instances where medications were not documented as administered. Specifically, the MAR for September and October 2023 lacked evidence of glipizide administration on multiple dates, the MAR for November 2023 lacked evidence of ciprofloxacin administration on several shifts, and the MAR for January 2024 lacked evidence of cefdinir administration on two occasions. The Director of Nursing (DON) confirmed the discrepancies in the MARs and stated that it was the expectation for nursing staff to document medication administration at the time of administration. The facility's policy on Medication Administration, dated 10/15/19, also required nursing staff to document and sign the electronic MAR after administering medications. Despite these policies, the documentation was incomplete, leading to the identified deficiency.
Inaccurate Staffing Reporting and Inadequate Weekend Coverage
Penalty
Summary
The facility failed to accurately report staffing requirements to adequately cover the resident population during weekends, as documented in the payroll-based journal (PBJ) requirements submitted to the Center for Medicare and Medicaid Services (CMS). The review of the facility's Certification and Survey Provider Enhanced Reporting System (CASPER) revealed excessively low weekend staffing for the months of July, August, and September 2023. The facility's staffing plan required three licensed nurses for the day shift and a 1:12 ratio for CNA coverage during the day, but the facility's nursing schedules and timesheets documented inadequate staffing coverage on multiple dates. For instance, on July 1, 2023, with a census of 51, the facility had only two CNAs working the day shift. Similar deficiencies were noted on other dates in July, August, and September, with either insufficient CNAs or LPNs working the day shift, failing to meet the required staffing levels as per the facility's plan. Additionally, the facility's night shift staffing plan required two licensed nurses and a 1:16 ratio for CNA coverage, but on July 30, 2023, with a census of 52, the facility had only two CNAs working the night shift. Interviews with the facility's staff revealed a lack of proper training and understanding of PBJ staffing reporting requirements. The Administrator explained that Payroll Clerks were responsible for PBJ reporting to CMS, but the Payroll Clerk 1 admitted to not being trained on the PBJ staffing reporting requirements and was unsure if the staff reviewed any information before reporting to CMS. Payroll Clerk 2 also expressed uncertainty about whether an average census per staff calculation was required to be submitted to CMS. The Clinical Operations Analyst, responsible for reporting PBJ to CMS, did not report CMS requirements for the PBJ report and was unaware of the need to report an average census and staffing requirements. The facility's policy on PBJ-Direct Care Hours Reporting, implemented in October 2022, required the facility to electronically submit timely and accurate direct care staffing information to CMS, including categories of work for each direct care staff member, resident census data, and information on direct care turnover and tenure, which was not adhered to in this case.
QAPI Committee Fails to Address Resident Safety and Infection Control
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to identify, develop, and implement plans of action for systemic issues related to beds placed against the walls for 37 of 49 residents. During a tour of the facility, it was observed that the beds of these residents were against the wall. The Executive Director and the Director of Nursing (DON) confirmed that the QAPI Committee had not addressed this issue, and the Safety Sub-Committee had primarily focused on employee safety rather than resident safety. The facility's QAPI Plan, revised in January 2024, documented that the Safety Committee should make recommendations to improve patient safety and monitor the implementation of corrective actions, which was not done in this case. Additionally, the facility failed to implement enhanced barrier precautions for residents with infections and did not complete the necessary training for staff members. The Resident Matrix documented several residents with infections, but no enhanced barrier precautions were in place. The DON confirmed that the QAPI Committee had not developed a plan for enhanced barrier precautions. Furthermore, two residents admitted with pressure injuries lacked documented evidence of wound care orders at the time of admission. The DON confirmed that the QAPI Committee had not identified issues with wound care orders or developed a plan to ensure orders were obtained upon admission, as required by the facility's QAPI Plan.
Failure to Include Medical Director in QAPI Committee Meetings
Penalty
Summary
The facility failed to maintain the required Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee members, specifically the inclusion of the Medical Director. Document review and interviews revealed that the QAPI Committee meeting attendee sheets for 10/27/23 and 11/22/23 lacked evidence of the Medical Director's participation. Additionally, the Director of Nursing (DON) confirmed that no QAPI Committee meeting was held in December 2023 and acknowledged the absence of the Medical Director in the meetings held in the last quarter of 2023. The Executive Director also confirmed the difficulty in contacting the Medical Director during this period. The facility's QAPI Plan, revised in January 2024, mandates the inclusion of the Medical Director in the QAPI Committee meetings.
Infection Control Deficiencies in Policy Review and FSBS Procedure
Penalty
Summary
The facility failed to ensure that its Infection Prevention and Control Plan (IPCP) was reviewed and updated annually to include current infection control standards. The IPCP was last reviewed on 10/19/22 and lacked documented evidence of any updates or reviews after that date. The policy did not address several critical infection prevention and control concerns, such as transmission-based precautions, environmental cleaning and disinfection, routine cleaning of resident care equipment, a list of reportable communicable diseases, and a process for monitoring staff illnesses. The Director of Nursing (DON) confirmed that the policy should have been reviewed on or before 10/19/23 but was not updated accordingly. Additionally, a Licensed Practical Nurse (LPN) performed a finger stick/blood sugar (FSBS) test for a resident in the community dining room, which violated infection control standards. The LPN placed the glucometer and used lancet on the dining room table without a barrier and did not disinfect the table afterward. The Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that FSBS should not be performed in common areas to maintain infection control standards and preserve the resident's dignity. The facility's policy required that glucometers be disinfected after each use, which was not followed in this instance.
Failure to Review and Update Antibiotic Stewardship Program Policy Annually
Penalty
Summary
The facility failed to ensure the Antibiotic Stewardship Program (ASP) policy was reviewed and/or updated annually, potentially affecting the entire resident census of 49. The ASP policy, last reviewed in November 2017, lacked documented evidence of annual review and did not include essential components such as a process for trending and reporting staff and resident infections, a process for communicating information at the time of transfer when a resident had an infection or was colonized, and a process for surveillance including outcomes such as SHEA's criteria. The Director of Nursing (DON) confirmed that the policy provided was the most current version and acknowledged that it should have been reviewed annually.
Failure to Administer Influenza Vaccine
Penalty
Summary
The facility failed to ensure that a resident was screened for eligibility to receive an influenza vaccine, provided with education regarding the vaccine, and offered the vaccine for the 2023/2024 influenza season. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, age-related physical debility, and adult failure to thrive, was admitted and readmitted to the facility. The clinical record lacked documented evidence of screening, education, and administration or declination of the influenza vaccine for the 2023/2024 season. The resident's state immunization record showed the last influenza vaccine was administered in 2019, with no record of vaccination for the current season. The Director of Nursing confirmed that the resident had requested the influenza vaccine, but it was not administered. The facility's policy, revised in 2022, stated that influenza vaccinations were to be offered annually from October 1st through March 31st, with documentation of education, consent, and administration or declination to be included in the resident's clinical record. However, the facility could not provide evidence that these steps were followed for the resident in question.
Failure to Screen, Educate, and Document COVID-19 Vaccination for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as Employee #1, was screened for eligibility to receive a COVID-19 booster vaccine, provided with education regarding the vaccine, and offered the vaccine. Employee #1 was hired on 10/09/22, and their COVID-19 Vaccination Record Card documented that they received a COVID vaccine on 02/01/21 and 02/22/21. However, the facility's records inconsistently documented the vaccination dates as 02/21/21 and 02/22/21. The facility was unable to provide documented evidence that Employee #1 was screened for eligibility for the most recent COVID vaccine, educated about the vaccine, and whether the vaccine was offered and either administered or declined. The facility's policy, dated 08/2023, stated that it maintained an immunization program against COVID-19 in accordance with national standards and offered COVID vaccinations approved for current use. The policy also required documentation of education regarding the risks, benefits, and potential side effects of COVID vaccines, the offering of the vaccine, the vaccination status of staff, and signed consent forms. Despite these requirements, the facility did not have the necessary documentation for Employee #1, indicating a failure to adhere to its own policy and national standards.
Failure to Ensure Timely Resident Rights Training for Staff
Penalty
Summary
The facility failed to ensure timely completion of resident rights training for two employees. Employee #4, a Registered Dietician hired on 02/20/23, completed the training on 06/05/23. Employee #12, an Infection Preventionist hired on 09/07/23, completed the training on 09/14/23. The Business Office Manager confirmed that resident rights training is required upon hire for all staff and acknowledged that Employees #4 and #12 did not complete the training within the required timeframe. The facility's policy, dated 10/2022, mandates that all direct and indirect care staff be educated on resident rights and facility responsibilities, which was not adhered to in these cases.
Failure to Ensure Timely Elder Abuse Prevention Training
Penalty
Summary
The facility failed to ensure timely completion of elder abuse prevention training for three employees. Employee #4, a Registered Dietitian, was hired on 02/20/23 but did not complete the training until 06/05/23. Employee #9, a Certified Nursing Assistant hired on 05/30/18, lacked documented evidence of completing the training for 2023. Employee #30, a Laundry Aide hired on 07/11/23, also lacked documented evidence of completing the training. The Human Resources Payroll Clerk confirmed that elder abuse training was required during orientation and annually thereafter, but these employees did not meet this requirement. The facility's policy, dated 10/09/14, mandates training on abuse prevention, intervention, investigation, and criminal reporting upon hire and annually, which was not adhered to in these cases.
Failure to Provide Timely Infection Control Training
Penalty
Summary
The facility failed to provide timely infection control training to all staff, as required by their infection prevention and control program. Specifically, three employees did not complete the training within the mandated timeframe. Employee #4, a Registered Dietician hired on 02/20/23, had no documented evidence of infection control training for 2023. Employee #6, the Dietary Manager hired on 11/09/23, completed the training one day late on 11/10/23. Employee #12, the Infection Preventionist hired on 09/07/23, completed the training seven days late on 09/14/23. The Business Office Manager confirmed that all staff were required to complete infection control training upon hire and acknowledged the delays for these employees. The facility's policy, last updated in 12/2022, mandates that all direct care staff must take sufficient infection control training and demonstrate competency in infection control skills.
Failure to Ensure Timely Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure compliance and ethics training was completed timely for five employees. Employee #2, hired as the Director of Nursing, and Employee #4, hired as the Registered Dietician, both lacked documented evidence of compliance and ethics training. Employee #3, hired as the Activity Manager, completed the training significantly late. Employee #9, a Certified Nursing Assistant, and Employee #20, a Housekeeper, also had delayed or missing documentation of their compliance and ethics training. The Business Office Manager confirmed that compliance and ethics training was required for all staff upon hire and acknowledged the deficiencies in timely training completion for these employees. The facility's training requirements document, updated in December 2022, mandated compliance and ethics training for new and existing staff, contractors, and volunteers.
Behavioral Health Training Deficiency
Penalty
Summary
The facility failed to ensure that behavioral health training was completed for 7 out of 20 sampled employees. These employees included the Executive Director, Activity Manager, Registered Dietician, Dietary Manager, MDS Coordinator, Infection Preventionist, and a Certified Nursing Assistant. The personnel records for these employees lacked documented evidence of the required behavioral health care training, which was confirmed by the Business Office Manager. The facility's document titled 'Covenant Care Employee Training Requirements,' updated in December 2022, indicated that behavioral health training was a mandatory program for all staff, contractors, and volunteers. Despite this requirement, the facility did not provide the necessary training to the identified employees, leading to a deficiency in compliance with the established training protocols.
Failure to Maintain a Homelike Environment Due to Overhead Paging
Penalty
Summary
The facility failed to provide a homelike environment by utilizing an overhead paging system to communicate with staff. This system was observed to be used multiple times across various dates and locations within the facility, including the A hallway, B hall, and near the nurses' station. The overhead pages were heard at different times of the day, indicating calls on different lines, which contributed to excessive noise levels within the facility. An interview with the Assistant Social Worker revealed that while personal items and room decorations helped create a homelike environment, factors such as med carts, noise from call lights, limited privacy, and excessive noise detracted from it. The facility's policy on maintaining comfortable sound levels stated that overhead paging should be limited to emergency situations and necessary care and treatment of residents. However, the frequent use of the overhead paging system was found to be inconsistent with this policy, thereby failing to maintain a homelike environment as required by the facility's Resident Rights document.
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Two residents admitted with indwelling Foley catheters did not have physician orders obtained or implemented for catheter care and management. Nursing documentation and MDS entries showed the presence of Foley catheters, but the EHR lacked orders for catheter maintenance, monitoring, or justification for continued use. One resident was observed with a full urine meter bag that had not been emptied, reported no routine cleansing of the insertion site, and had an undated, loose stabilizer, with family stating they often performed cleaning due to inconsistent staff care. CNAs and RNs confirmed the absence of catheter care orders and related documentation, and the DON verified that expected admission orders for Foley size, justification, irrigation as needed, and twice-daily catheter care were not obtained, in contrast to facility policies.
A resident with type 1 DM and insulin orders requiring MD notification for BG values outside set parameters experienced multiple episodes of hypoglycemia, including documented BG readings in the 40s. Nursing notes showed insulin was held and hypoglycemia treated, but there was no documentation that the physician was notified of these low BG values as required. Later, the resident was found unresponsive and clammy with a BG of 31 mg/dl; an RN administered oral glucose gel even though the resident could not safely swallow and the standing order required Glucagon SQ/IM for unresponsive residents with hypoglycemia. The BG remained critically low until EMS arrived and administered IV dextrose, after which the resident briefly aroused and then coded, ultimately expiring. Leadership and clinical staff confirmed that physician notification had not occurred for prior low BG readings and that the hypoglycemia treatment orders were not followed during the unresponsive episode.
A resident with type 1 DM and diabetic autonomic neuropathy was found unresponsive and clammy by a CNA during the night. An RN obtained a blood glucose of 31, administered oral glucose gel outside of order guidelines, and did not administer ordered Glucagon. A repeat blood glucose remained 31, EMS administered D10, the resident briefly regained consciousness, then became unresponsive, CPR was initiated, and the resident expired. The Administrator/Abuse Coordinator reported there was no accessible documentation of the required abuse/neglect investigation, stating that records previously maintained by the former DON could not be located and some electronic files were inaccessible after a change of ownership, contrary to the facility’s abuse/neglect policy requiring a complete, documented investigation.
A resident with multiple chronic conditions and intact cognition was sent to the hospital under an L2K after an altercation involving verbal aggression and throwing an ashtray. While the hospital later discharged the resident with a psychiatric diagnosis and arranged transport back, facility leadership had already decided, based on an unwritten practice to deny readmission for L2K cases, that the resident would not be accepted back and reassigned the bed despite available capacity. Hospital calls about the transfer were routed to case management, which confirmed the denial, and when the resident arrived with EMTs and discharge papers, staff refused readmission, did not accept the paperwork, did not provide medications, and called law enforcement, resulting in the resident being trespassed from the property even though staff knew the resident had no housing or resources. The facility had a written transfer/discharge policy allowing return after acute care but no written criteria for residents hospitalized under an L2K, and staff followed only verbal direction from leadership.
A fire response led to residents being evacuated to a courtyard while doors to the building remained closed, during which a family member, upset about not being allowed to enter, recorded a video capturing multiple residents, staff, and visitors without consent and posted it on social media with a disparaging narrative. Several residents with complex medical conditions, including COPD, cerebral infarction, tracheostomy status, Parkinson’s disease, schizoaffective disorder, dementia, and others, later recognized themselves in the widely viewed post and reported feeling upset, offended, or that their privacy was violated. Some residents and representatives noted they were not given the opportunity to consent, and one resident reported that staff told the individual to stop filming but the recording continued, contrary to facility policy prohibiting unauthorized imaging and transmission of resident images.
The facility failed to timely report two separate incidents to the state agency: a fire-related event in the main dining room and unauthorized videotaping of multiple residents by a family member. In the first incident, smoke and a burning electrical odor were observed in the main dining room, residents were evacuated, and the fire department later determined the source was a seized HVAC fan blower motor; the room was found to have only one smoke detector at the entrance, with the rest of the large space lacking detection. In the second incident, while residents were evacuated during the same code red, a family member recorded residents’ faces without consent and posted the footage on social media, contrary to facility policies that classify such conduct as a violation of resident rights and abuse requiring reporting within 24 hours. Both incidents were reported to the state agency 11 days after they occurred.
A resident with multiple comorbidities, including CHF, prior CVA, anxiety, depression, muscle weakness, and impaired mobility and coordination, was subjected to rough incontinence care by a CNA. A PT who entered the room during a brief change observed the CNA roll the small-statured resident onto their side, noted redness on the resident’s buttocks, and saw the CNA roughly wipe the area. The resident cried out in pain, stating that it hurt, but the CNA did not respond or adjust care and continued the brief change. The facility’s investigation concluded the CNA had been rough and dismissive of the resident’s expressed pain, in violation of the facility’s abuse policy.
A resident with cerebral palsy and dysphagia had an outdated and incomplete personal property inventory, despite ongoing additions of items such as clothing, plants, books, and sentimental objects. The resident’s guardian later found the resident’s cupboard completely empty, although it had previously contained food, candy, Tupperware, ceramic mugs from vacations, a soup bowl from a great grandmother, gift cards, and greeting cards from deceased relatives. Staff, including a CNA and SW, acknowledged that many belongings in the room were never added to the inventory list, and the DON informed the SW that the resident’s items had been removed and placed in a secure cabinet in preparation for a survey, with gift cards unaccounted for. This failure to maintain an accurate inventory and the removal of belongings without notifying the guardian violated the resident’s right to retain and use personal possessions.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school and told a CNA that a teacher had pulled their hair, pinched them, yelled at them, and refused to change them, while documentation also showed a 9 cm abrasion on the resident’s back after a reported school incident. The CNA immediately brought the resident to the SW, who, according to the CNA, dismissed the allegation, stated they did not believe the teacher, and referenced the resident’s history of fabricating stories, then the CNA reported the concern to the DON. The DON acknowledged being informed that the resident returned crying and soiled and notified the Abuse Coordinator, but neither the DON nor the Abuse Coordinator reported the allegation to the SA, law enforcement, ombudsman, physician, or responsible parties, despite facility policy requiring immediate reporting of any alleged or suspected abuse or injuries of unknown source.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school distressed and reported to a CNA that a teacher had pulled the resident’s hair, pinched the resident, yelled, and refused requested care. The CNA brought the resident to the SW, who expressed disbelief in the allegation, characterized the resident as fabricating stories, and referenced potential school expulsion and limiting friend visits. Nursing documentation the same day noted a new 9 cm abrasion on the resident’s upper back present on return from school. The DON, who was notified by the CNA, did not interview the resident, teacher, or SW and did not review the clinical record or complete a wound assessment. The Abuse Coordinator, though aware of behavioral issues reported by the teacher, did not obtain statements, review the record, or initiate any abuse investigation, despite facility policy outlining required investigative steps for abuse and neglect allegations.
Failure to Obtain and Implement Foley Catheter Care Orders
Penalty
Summary
The facility failed to obtain and implement physician orders for the care and management of indwelling Foley catheters for two residents. One resident was admitted with diagnoses including polyneuropathy, acute respiratory failure, and acute pulmonary edema, and both the nursing documentation evaluation and admission MDS documented the presence of an indwelling Foley catheter. However, the medical record contained no physician orders for Foley catheter care and maintenance. On review, the DON confirmed that monitoring and maintenance orders for the Foley catheter were expected but were not present in the record. Another resident, admitted with prostate cancer, benign prostatic hyperplasia, and a recent UTI treated in the hospital where a Foley catheter was placed, was observed with a urine meter bag containing 350 ml of urine that had not been emptied that morning. The resident and family reported that the Foley catheter had not been replaced since admission and that the insertion site was not routinely cleansed, with the family often providing cleaning due to inconsistent staff care. A CNA confirmed the urinary bag was full and should have been emptied at the start of the shift, and noted the catheter stabilizer was undated and loose. Review of the EHR by RNs showed no care or management orders for the indwelling catheter since admission and therefore no documentation of routine catheter care. The DON confirmed that admission orders for Foley size, justification for use, irrigation as needed, and twice-daily catheter care, including cleaning around the insertion site and emptying the bag, had not been obtained or entered, resulting in no documented catheter care in the MAR, contrary to facility policies requiring valid justification and admission assessment with communication to the physician.
Failure to Notify Physician of Recurrent Hypoglycemia and to Follow Hypoglycemia Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to protect a diabetic resident from neglect when nursing staff did not follow physician orders for monitoring and responding to hypoglycemia and did not notify the physician of critical low blood glucose (BG) values. The resident had type 1 diabetes mellitus with circulatory complications and diabetic autonomic neuropathy and was ordered multiple insulin regimens, including Lantus and sliding-scale Insulin Aspart, with explicit instructions to notify the physician for BG less than 80 mg/dl or greater than 350 mg/dl. The resident also had PRN orders for oral glucose gel for BG less than 70 mg/dl with symptoms of hypoglycemia if able to swallow, and for Glucagon to be given SQ or IM for BG less than 70 mg/dl with signs of hypoglycemia when the resident was unable to swallow or was unresponsive. The resident’s care plan included monitoring, documenting, and reporting signs and symptoms of hypoglycemia. On two separate dates prior to the fatal event, the resident experienced documented episodes of hypoglycemia with BG readings below the ordered parameters. A progress note documented that on one date the resident’s Lantus was held due to a blood sugar of 46 mg/dl and that Glucagon was administered, with a plan to recheck. Another progress note documented a low blood sugar of 47 mg/dl prior to breakfast, after which the resident was given juices and other fluids and the BG increased to 103 mg/dl. During this second episode, staff discussed with the resident the concern about hypoglycemia and suggested contacting the provider to lower the Lantus dose, but the resident declined changes and staff planned to remind the next shift to offer midnight snacks. The clinical record, however, lacked documentation that the physician was notified of these BG readings below 80 mg/dl, despite the physician order requiring notification for BG values outside the specified parameters. On the night of the fatal incident, a CNA found the resident unresponsive and clammy. An RN assessed the resident and obtained a fingerstick blood glucose of 31 mg/dl. Despite the resident being unresponsive and unable to drink or eat, the RN administered one tube of oral glucose gel, which was not in accordance with the physician’s order that specified Glucagon for hypoglycemia in residents who were unable to swallow or unresponsive. A repeat BG 20 minutes later remained 31 mg/dl. Emergency Medical Services were called, and when they arrived, the resident’s BG was 19 mg/dl. EMS administered D10, after which the resident briefly became arousable and then became unresponsive again, leading to CPR and subsequent death. Facility leadership, including the DON and CNO, confirmed that the physician had not been notified of the earlier low BG readings and that Glucose gel was inappropriately used instead of Glucagon when the resident was unresponsive, constituting a failure to follow physician orders and a failure to report changes in condition as required by facility policy and job descriptions.
Failure to Document Investigation of Neglect-Related Hypoglycemic Event and Death
Penalty
Summary
The deficiency involves the facility’s failure to provide documented evidence of a thorough investigation into an incident suspicious for neglect involving Resident #8. Resident #8 had diagnoses including type 1 diabetes mellitus with circulatory complications and diabetic autonomic (poly) neuropathy. According to the Facility Reported Incident (FRI), a CNA found the resident unresponsive and clammy at approximately 1:00 AM. An RN assessed the resident, obtained a blood glucose result of 31, and administered oral glucose gel outside of order guidelines instead of administering the prescribed Glucagon per physician order. A repeat finger-stick blood glucose remained 31, EMS was called, and EMS administered 10% Dextrose. The resident briefly regained consciousness, then became unresponsive again, CPR was initiated by EMS, and the resident expired. The Administrator/Abuse Coordinator stated there was no documentation of the facility’s investigation of this incident. The Administrator/Abuse Coordinator reported that the former DON had the investigation documentation, but it could not be located in the former DON’s office, and many electronic files were inaccessible following a change of ownership in February 2026. This lack of available documentation was inconsistent with the facility’s Abuse, Neglect, and Exploitation policy, which required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, and providing complete and thorough documentation of the investigation.
Failure to Readmit Hospitalized Resident Under L2K and Lack of Criteria for Psychiatric Holds
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was readmitted following a hospital transfer under a legal hold (L2K) and the absence of written criteria or policy governing residents hospitalized under an L2K. The resident had multiple medical diagnoses, including diabetes mellitus with long-term insulin use, chronic right lower leg ulcer, cellulitis, infective myositis, muscle weakness, difficulty walking, reduced mobility, pulmonary embolism, hypertension, chronic pain, and anxiety disorder, and had an intact cognition score (BIMS 15/15). After a resident-to-resident altercation in the smoking area, during which the resident was verbally aggressive and threw an ashtray, the physician ordered an L2K and the resident was transferred to the hospital. Facility staff, including the DON and RN, described the L2K as used when a resident was a danger to self or others and confirmed the resident was sent out under an L2K. Hospital records documented that the resident’s behavioral symptoms stabilized in the emergency department, were assessed as secondary to psychiatric illness, and that the resident remained a danger to self and unable to care for self, with ongoing psychotic behavior noted. The hospital ultimately discharged the resident with a diagnosis of acute situational disturbance and arranged transportation back to the facility. Prior to the resident’s return, the hospital made multiple calls to the facility about the transfer, which were routed to case management; the receptionist reported being informed by case management and the marketing director that the facility would not readmit the resident. The marketing director stated that facility practice was to deny readmission for residents sent out under an L2K and that the decision not to readmit this resident was made in advance based on direction from the administrator, after which the resident’s bed was reassigned despite available capacity in the building. When the resident arrived back at the facility with EMTs and hospital discharge papers, staff informed the resident that readmission would not occur, that belongings had been packed, and that the previous room was occupied. Staff did not contact the hospital for clarification because the resident did not want to return to the hospital. The facility did not accept the discharge paperwork, did not provide medications, and did not readmit the resident, with the DON stating there were no physician orders and that residents sent to the hospital were considered discharged once admitted. Law enforcement was called, the resident was issued a trespass notice, and was escorted off the property, despite the facility’s awareness that the resident had no home, no local family, and no resources. The resident reported staying at a nearby bus stop for several days without food, money, or medications, and later presented to the hospital with worsening leg swelling and a confirmed DVT after not receiving prescribed medications. The facility’s existing transfer and discharge policy stated that residents transferred to an acute care setting were permitted to return upon discharge, and the DON confirmed there was no written policy governing L2K or hospital readmissions, with staff following only verbal direction from leadership.
Unauthorized Social Media Video of Residents During Fire Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ privacy rights were protected when an unauthorized video recording of residents during a fire response was made and posted on social media. During a Code Red related to smoke from the dining room ceiling, residents were evacuated to the outdoor courtyard while doors to the facility remained closed under the fire protocol. A resident’s family member, upset about not being allowed to enter from the courtyard, began video recording the scene, capturing multiple residents, staff, visitors, and minors without consent. The 45‑second video was then uploaded to social media with a narrative criticizing the facility’s handling of the event and referring to residents in a disparaging manner, and it subsequently received extensive public engagement in the form of comments, likes, and shares. The facility identified approximately 20 residents who were present in the courtyard and appeared in the video, including residents with significant medical conditions such as acute on chronic respiratory failure, COPD, cerebral infarction, encephalopathy, gastrostomy and tracheostomy status, protein‑calorie malnutrition, bilateral above‑knee amputations, cerebral palsy, seizure disorder, schizoaffective disorder, Parkinson’s disease, pleural effusion, bipolar disorder, atrial fibrillation, polyneuropathy, and dementia. Several residents personally confirmed being evacuated to the courtyard during the incident and later recognizing themselves in the posted video. One resident reported witnessing a staff member instruct the person filming to stop, but the individual continued recording despite this direction. Multiple residents and resident representatives reported feeling upset, offended, or violated by being recorded and included in the social media post without their consent. Some residents stated they would have wanted the opportunity to give or withhold consent, and others expressed that the filming and posting were inappropriate and that they took offense to the situation. Public guardians and family members of residents with dementia or under guardianship also expressed disapproval of their residents being recorded without consent and used in a social media video. The facility’s own policy on videotaping, photographing, and imaging of residents states that transmitting unauthorized images of any resident via internet or social media is a violation of residents’ rights and that any such image or recording that may be construed as humiliating or demeaning is considered resident abuse and must be reported and investigated, underscoring that the incident constituted a failure to protect resident privacy and dignity.
Failure to Timely Report Fire Incident and Unauthorized Resident Videotaping
Penalty
Summary
The facility failed to timely report to the state agency a fire-related incident that occurred in the main dining room. On 03/08/2026 at 12:50 PM, a maintenance assistant observed smoke coming from a ceiling vent in the main dining room along with a burning electrical odor, activated the fire alarm, and staff evacuated residents to the courtyard while the fire department responded. The fire department determined the source was a seized HVAC fan blower motor whose belt generated smoke briefly until failure, with no fire, heat, injuries, or suppression activity. During the investigation, the surveyor observed that the 3,363 square foot main dining room was protected only by a single photoelectric smoke detector at the entrance providing egress coverage, with the remainder of the space, including the tray ceiling, lacking detection, which appeared inconsistent with NFPA 72 (2010) Section 17.7.3.2.1. The facility did not submit a report of this incident to the state agency until 03/19/2026, which was 11 days after the event. The facility also failed to timely report an incident of unauthorized video recording and social media release involving multiple residents. On 03/08/2026, during the same code red for unidentified smoke in the dining room and while residents were evacuated to the outdoor courtyard awaiting clearance from the fire department, a resident’s family member recorded unauthorized video footage that included residents’ faces without their consent and later posted this footage on social media. Staff and resident interviews, review of social media footage, and facility documents on 03/20/2026 confirmed the unauthorized videotaping and social media release. The facility’s policy on videotaping and photographing residents, dated 10/01/2021, stated that transmitting unauthorized images of any resident via email, internet, or social media is a violation of resident rights and that any images or recordings that may be construed as humiliating or demeaning are considered abuse, which should be reported and investigated as such. The facility’s abuse policy defined exploitation as taking advantage of a resident for personal gain and required that incidents of abuse be reported to the state survey agency no later than 24 hours if they did not result in serious bodily harm; however, the facility did not report this incident to the state agency until 03/19/2026, 11 days after it occurred.
Failure to Protect Resident From Rough and Painful Incontinence Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a CNA during incontinence care. The resident had multiple medical conditions, including acute chronic systolic congestive heart failure, cerebral infarction due to embolism of the right middle cerebral artery, anxiety disorder, depression, muscle weakness, difficulty walking, bilateral localized swelling, and lack of coordination. During a brief change in the resident’s room, a Physical Therapist entered after knocking and announcing therapy and observed the CNA roll the small-statured resident onto their side. Upon removal of the brief, the therapist noted the resident’s bottom appeared red. The Physical Therapist then observed the CNA roughly wipe the resident’s bottom, after which the resident verbalized, “ow, that hurt.” The CNA did not respond to the resident’s expression of pain and continued changing the brief without acknowledging or addressing the resident’s discomfort. The facility’s investigation, as described by the Administrator, determined that the CNA had been rough with the resident during the brief change and was dismissive of the resident’s verbal call out when the resident felt pain. This conduct was contrary to the facility’s abuse policy, which states that each resident has the right to be free from abuse, including physical abuse or mistreatment, and that the facility would implement processes to ensure residents are not subject to abuse by staff.
Resident Belongings Removed and Poorly Inventoried Without Notification
Penalty
Summary
The deficiency involves the facility’s failure to respect a resident’s right to retain and use personal possessions and to maintain an accurate inventory of those belongings. The resident, who had cerebral palsy, a developmental motor disorder, and dysphagia, was admitted with an inventory list that included clothing, an E‑Reader/iPad, a backpack, a stuffed animal, hair accessories, a wheelchair tool kit, a bathing suit, an iPad stand, a wheelchair, and cushions. The most recent inventory list on file was dated in 2023 and did not reflect all of the resident’s belongings. Staff, including a CNA and the SW, acknowledged that many items present in the resident’s room, such as plants, books, stuffed animals, lotions, blankets, clothing, jackets, nightlights, and pictures, were not documented on the inventory sheet, and that the list was “quite bare” and required updating. The resident’s Guardian reported arriving to find the cupboard in the resident’s room completely empty, although it had previously contained food items, candy, Tupperware, ceramic mugs from vacations, a soup bowl from the resident’s great grandmother, approximately $75 in gift cards, and greeting cards from deceased relatives. The Guardian was not notified that these items had been removed and filed a grievance about the missing property. The SW later learned from the DON that staff had removed the resident’s belongings from the room and placed them in a secure cabinet due to an upcoming survey, and that the gift cards could not be located. The facility’s own policies stated that all personal effects were to be inventoried upon admission and that all items subsequently brought into the facility were to be added to the inventory form, but this was not done for this resident, and belongings were removed from the room without prior notification to the Guardian or documentation on the inventory list.
Failure to Report Alleged School Abuse of a Resident to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency (SA) as required. A resident with spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder returned from school after being picked up due to behaviors. Alert progress notes documented that upon return, the resident was calm and toileting was performed, during which the resident reported to a floor CNA that a teacher at school had abused them, specifically by pulling their hair, pinching their arm, yelling at them, and refusing to change them when requested. The resident became emotional and cried while making this report. The CNA immediately took the resident to the Social Worker (SW) and reported the allegation in the resident’s presence. According to the CNA’s account, the SW disregarded the resident’s report, stated they did not believe the teacher would do what was claimed, and characterized the resident’s account as a fabricated story. The SW also told the resident that if they had another behavior, they would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA then left the SW’s office with the resident and reported the concerns to the DON. A nursing progress note from the same day documented that the resident had an incident at school in which they slid partially out of their wheelchair and scraped their back, resulting in a 9 cm abrasion on the upper back. In subsequent interviews, the CNA reiterated that the resident had reported the teacher pulled their hair, pinched their underarms, yelled at them, and refused to change them, and that the resident stated they were being abused. The CNA stated they notified the DON and later reported the concern to the ombudsman. The SW, when interviewed, described being responsible for case management and acknowledged that abuse allegations should be reported to the Abuse Coordinator or DON and then to the SA, and identified various forms and signs of abuse. The SW recounted a prior incident in which the resident had alleged the teacher hit them first, but the SW believed the resident was not an accurate historian and considered the statement confabulatory. The SW confirmed there was documentation of a 9 cm abrasion on the resident’s back and acknowledged the note indicated the resident returned from school with an injury. The DON stated uncertainty about the process for abuse investigation and reporting, including not being sure who the designee for the Abuse Coordinator would be. The DON reported being told that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON stated they immediately notified the Abuse Coordinator but did not report the concern further. The Abuse Coordinator/Administrator defined abuse and neglect and stated that the facility would be responsible for reporting any allegation of abuse, neglect, exploitation, or misappropriation to law enforcement, the ombudsman, the SA, the physician, and responsible parties, regardless of whether it occurred inside or outside the facility. The Abuse Coordinator acknowledged being notified of the resident’s increased behaviors and being told the resident kicked at the teacher, but was unaware of the resident’s allegation that the teacher hit them first until informed later by the SW. The Abuse Coordinator confirmed that no reports had been made to law enforcement, the ombudsman, the SA, the physician, or responsible parties after being notified of the alleged abuse. The facility’s abuse policy required the Administrator or DON to notify the SA, ombudsman, child protective services, and law enforcement when an alleged or suspected case of neglect, injuries of unknown source, or abuse was reported, but this did not occur in this case.
Failure to Investigate Resident’s Allegation of Abuse by External Caregiver
Penalty
Summary
The facility failed to investigate an allegation of abuse involving Resident #6 after the resident reported being abused by a school teacher. Resident #6, who had spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder, returned from school on 02/10/2026 and was documented as calm and collected initially. Alert progress notes recorded that after toileting, the resident told a floor CNA that the resident was being abused by the teacher, naming the teacher and describing hair pulling, arm pinching, and yelling. The resident became emotional and cried while reporting this to the CNA. The CNA immediately took Resident #6 to the Social Worker (SW) with the resident present. According to the CNA’s account and documentation, the SW disregarded the resident’s report, stated disbelief that the teacher would do what was alleged, and characterized the resident’s account as a fabricated story. The SW also told the resident that if the resident had another behavior, the resident would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA and resident then left the SW’s office, and the CNA reported the concerns to the DON. The CNA did not speak with the Abuse Coordinator at that time but documented the experience in the electronic health record and later reported the concern to the ombudsman. A nursing progress note from the same date documented that the resident returned from school with a 9 cm abrasion on the upper back, described as resulting from sliding partially out of the wheelchair and scraping on a pedestal. In subsequent interviews, the SW stated that if notified of an abuse allegation, the SW would report it to the Abuse Coordinator or DON and that abuse included physical and verbal abuse and neglect. The SW recounted that about a month prior, the teacher had reported the resident hit and kicked the teacher, and the resident had responded that the teacher hit the resident first; the SW believed the resident had no physical marks and considered the resident an unreliable historian. A behavior progress note effective 02/10/2026 documented that the SW found the resident’s statement about the teacher hitting first to be confabulatory. The SW acknowledged feeling sorry for the teacher, not believing the teacher would hit the resident, and confirmed that the resident’s right to visit a friend was not contingent on behavior. The SW also acknowledged the note indicating a 9 cm abrasion on the resident’s back and initially believed the resident fell off the toilet, despite documentation that the injury was present upon return from school. The DON reported uncertainty about the abuse investigation and reporting process, including not being sure who the designee for the Abuse Coordinator would be. The DON stated that on the day of the incident, the CNA reported that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON did not interview the resident, the teacher, or the SW, and did not review the resident’s electronic health record after being notified of the alleged abuse. The DON was unaware of the alert notes and nursing progress note documenting the new abrasion and acknowledged that a wound assessment should have been completed but was not. The Abuse Coordinator/Administrator described that an abuse investigation should include review of records, shift assignments, and interviews with residents, family, and staff, and confirmed that the facility was responsible for reporting allegations of abuse occurring inside or outside the facility. The Abuse Coordinator stated being notified only of the resident’s increased behaviors and the teacher’s report that the resident kicked at the teacher, and did not speak with anyone else about the allegation at that time. The Abuse Coordinator later learned from the SW that the resident had said the teacher hit first, but because the resident could not specify where, the SW deemed the statement unreliable. The Abuse Coordinator did not obtain written statements from the resident, CNA, SW, or DON, and did not review the resident’s clinical record. The Abuse Coordinator confirmed that no investigation into the allegation of abuse was initiated, despite facility policy requiring, at a minimum, review of the incident report, medical record, and interviews with the reporter, witnesses, resident, staff, roommate, family, and visitors.
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