Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pershing General Hospital Snf during CMS and state inspections, most recent first.
Improper food storage and kitchen hygiene practices were observed when an employee's unlabeled drink was stored in a resident refrigerator, a cook wore dangling jewelry on the tray line, staff had uncovered sideburns and facial hair while handling food, and a dietary aide returned to the tray line before washing hands. The Dietary Manager confirmed these practices and referenced facility policies requiring resident-only refrigerator use, no dangling jewelry, hair coverings for hair and facial hair, and hand hygiene before returning to food prep areas.
An RN failed to perform hand hygiene or change gloves during gastric tube site dressing care for a resident with dysphagia and prior stroke diagnoses. A staff member also stored a cell phone and lip balm in a medication cart drawer on top of resident tissues, and a housekeeper handled a soiled mop pad without gloves and then touched a housekeeping cart, binder, and nutrition room door handle without hand hygiene. The DON, IP, and staff confirmed these actions did not follow facility infection control and storage practices.
The facility failed to timely report an abuse/neglect investigation result to the SA for one resident after a fall with a change in mentation, and failed to submit an initial FRI for another resident’s allegation of rough handling and refusal of VS within the required timeframe. The DON/AC confirmed the late reporting, noted the investigation report was not sent as required, and stated the alleged staff were not suspended immediately because of the delay in reporting.
A resident with RA and major depressive disorder was upset when a fish tank that had belonged to the resident’s deceased roommate and was later given to the resident was removed from the room without permission and placed in a common area. The AD said maintenance removed the tank at the AD’s request, while the DON, SW, US, and CNAs denied documentation of the tank’s disposition, the resident’s ownership, or any documented discussion about safety concerns or alternatives. The resident was documented as refusing activities because of the issue.
A resident with dementia, depression, and physical debility died in the facility, and the MDS assessment completed after death was not transmitted to CMS until more than a month later. The MDS RN confirmed the record should have been submitted within 14 days of the resident’s death and stated the facility did not have a policy for MDS submission validation reporting, relying instead on the RAI Manual.
Controlled Medication Not Documented at Time of Administration: An LPN administered Ativan to a resident with anxiety disorder and borderline personality disorder but did not document the dose in the controlled substance log at the time of administration. During observation with the DON, the LPN acknowledged the omission and the DON stated the controlled substance should have been documented when given so the medication count would be accurate.
A facility failed to document that two residents or their representatives were given the chance to change their decision before flu vaccine administration. Both residents had earlier acceptance forms, but the later vaccine consent forms were left unsigned and did not show that screening or informed consent was completed at the time of administration. The DON and IP acknowledged the missing documentation and stated staff often relied on the prior acceptance form when a resident was not their own responsible party.
Missing documented consent for COVID-19 vaccine administration: Two residents had COVID-19 vaccine acceptance forms on file, but the vaccine administration records did not show that consent was re-confirmed at the time the shots were given or that the resident/representative was asked again if they still wanted the vaccine. The DON and IP stated staff were expected to obtain informed consent before each vaccine and acknowledged the documentation was missing.
The facility failed to ensure annual elder abuse prevention training was completed for an employee who worked as a Speech Therapist Contractor. The personnel record showed prior abuse training, but no documentation of the required annual training for the current year. The Administrator confirmed the training had not been completed, despite the facility policy requiring abuse and neglect prevention training upon hire and annually thereafter.
Incomplete Posted Nurse Staffing Information: The facility failed to post nurse staffing information that included the actual hours worked per shift for licensed and unlicensed nursing staff responsible for resident care. The posted staffing data was missing those hours on multiple observed days, and the DON stated she was unaware of the requirement and confirmed the posting did not include the actual hours worked.
Two residents had inaccurate MDS 3.0 assessments: one was incorrectly documented as receiving an antidepressant, despite no current order or administration, and another was recorded as using a floor mat alarm, though no such device was ordered or present. The DON confirmed both MDS entries were incorrect.
A resident with dementia and foot drop was observed multiple times with heel boots applied without a physician's order and not correctly positioned, as the boots were unfastened and the heels were not aligned with the pressure redistribution opening. Nursing staff and the DON confirmed the lack of an order and improper application, despite facility policy requiring both an order and correct use of such equipment.
A newly hired RN did not complete required behavioral health care training within the facility's specified timeframe. Personnel records lacked documentation of the training, and both HR and administration confirmed the oversight, despite facility policy mandating completion within 40 hours of hire.
A facility failed to create a care plan for a resident with bilateral lower extremity edema, despite a physician's order for compression stockings to manage swelling associated with bilateral primary osteoarthritis of the knee. The resident's clinical record lacked documentation of a care plan, and the DON confirmed this oversight, which was contrary to the facility's policy requiring individualized care plans.
The facility failed to revise care plans for a resident receiving psychotropic medication and two residents at risk of falls. One resident's care plan did not include physician-identified behaviors necessary for medication administration. Another resident's care plan lacked new interventions after a fall, despite suggestions from the IDT. A third resident experienced multiple falls, and the care plan was not updated with effective interventions. These deficiencies highlight the facility's failure to ensure comprehensive care plans and appropriate interventions.
Two residents with a history of falls and cognitive impairments did not receive appropriate fall prevention interventions. One resident's care plan was not updated with recommended grip strips, and a Morse scale evaluation was not completed. Another resident experienced multiple falls without effective interventions being added to the care plan, despite therapy staff deeming a proposed intervention inappropriate. The facility did not adhere to its fall prevention policy, which requires care plan updates and post-fall evaluations.
The facility failed to complete timely annual performance evaluations for three CNAs. An Activity Director/CNA and two CNAs did not have their evaluations documented for 2024, despite the facility's policy requiring annual evaluations by the anniversary date of hire. The Human Resources Director confirmed the oversight.
A resident did not receive prescribed Restasis Ophthalmic Emulsion due to unavailability in the facility, despite multiple requests to the pharmacy. The facility lacked a documented procedure for the safe procurement of medications, as confirmed by the DON and Administrator.
A facility failed to ensure behaviors monitored were associated with specific conditions indicated by physicians for psychotropic medication use. A resident with major depressive disorder and vascular dementia was prescribed Seroquel and Cymbalta, but behavior monitoring was not personalized to the medication. Additionally, five other residents had psychotropic medications without specific conditions documented for use. The facility's policy required daily monitoring of resident-specific behaviors, but this was not followed, leading to the deficiency.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate. An RN omitted Metoprolol during a medication pass for a resident with heart failure, due to nervousness while being observed. The error was corrected after verification of the medication cup contents.
A resident with heart failure did not receive their prescribed Metoprolol Tartrate during a medication pass due to an RN's omission. The RN, who was nervous about being observed, failed to include the medication in the cup before administration. The facility's policy requires medications to be administered as per physician's orders, and omissions are considered errors.
The facility failed to document psychotropic behavior monitoring for six residents and inaccurately recorded medication administration for another resident. Behavioral Health Records had blank spaces for required monitoring, and a resident's MAR incorrectly showed administration of unavailable eye drops. The DON confirmed these documentation errors.
The facility failed to provide the Restorative Nursing Program (RNP) to 13 residents in need of restorative nursing services due to staffing changes and lack of documentation. The program was inactive from January to April 2024, affecting residents' baseline physical abilities.
The Administrator failed to maintain a Restorative Nursing Program (RNP) due to staffing changes, and the Abuse Committee did not properly investigate abuse allegations by misapplying the definition of abuse. The RNP was inactive from January to April 2024, and an abuse incident was unsubstantiated despite the employee admitting responsibility.
The facility failed to ensure that 10 out of 20 sampled staff members received mandatory QAPI training. The personnel records of various employees, including the DON, Registered Dietitian, CNAs, RN, LPN, Dietary Aides/Cooks, and Housekeeper, lacked documented evidence of completed QAPI training. The Administrator and Risk Manager acknowledged the issue and confirmed that the training had not been part of the onboarding process but would be included moving forward.
The facility failed to recognize and address verbal and physical abuse towards a non-verbal, quadriplegic resident by a CNA. Additionally, the Director of Nursing lacked the knowledge and skills to manage the Restorative Nursing Program, resulting in a lack of restorative care for residents over several months.
The facility failed to protect a resident's right to dignity and respect by updating a care plan to include sexual behaviors without evidence or assessment. This occurred after staff observed physical and verbal abuse by a CNA toward a cognitively impaired, non-verbal resident. The resident's guardian and other staff members questioned the validity of the claim, given the resident's limited mobility and non-verbal status.
A resident with limited mobility and non-verbal status was allegedly slapped by a CNA after the resident brushed the CNA's breast. The incident was witnessed and reported by the Food Services Supervisor, but the facility's investigation was unsubstantiated, citing a lack of negative psychosocial outcomes and no physical signs of injury. The facility did not take disciplinary action against the CNA.
The facility failed to implement its abuse policies regarding identification, investigation, protection, and reporting for an allegation of verbal and physical abuse toward a non-verbal, quadriplegic resident by a CNA. The incident was witnessed and reported, but the facility did not take appropriate disciplinary action, and the incident was unsubstantiated due to a lack of physical injury.
The facility failed to obtain informed consent from a resident's Guardian before placing an air mattress on a bariatric bed. The resident, who was quadriplegic, had no care plan addressing the air mattress, and there was no documented evidence of risk assessment or explanation of risks and benefits to the Guardian. The DON confirmed the air mattress was considered a restraint, and the facility's policy on restraints was not followed.
A resident with dementia fell in the dining area, struck their head, lost consciousness, and was transferred to the ER. Despite facility policies requiring such incidents to be reported to the State Agency (SA), the Administrator and Director of Nursing (DON) failed to report the fall, believing it did not meet the criteria for serious bodily injury.
The facility failed to notify the State LTC Ombudsman of a resident's discharge. The resident, with type II diabetes and COPD, was transferred to the hospital due to slurred speech and altered mental status and was discharged the next day. The MDS RN confirmed the notification was not submitted as required by facility policy.
The facility failed to ensure the accuracy of MDS assessments for three residents. One resident's MDS inaccurately documented an indwelling catheter, another's MDS incorrectly noted the use of an antipsychotic and bed rails as restraints, and a third's MDS misclassified an antiplatelet medication as an anticoagulant. These errors were confirmed by the MDS Coordinator.
The facility failed to follow physician's orders for insulin therapy for two residents with type II diabetes mellitus. Despite administering the correct insulin dosages, there was no documented evidence that the physician was notified when blood sugar levels exceeded 400, as required by the orders.
The facility failed to assess an air mattress for entrapment and restraint for a resident with multiple conditions, including quadriplegia and dementia. The necessary assessments, consents, and care plan were not completed, and the risks and benefits were not reviewed with the resident's guardian.
The facility failed to ensure proper care and documentation for a resident with an indwelling catheter. The resident did not have physician orders for ongoing catheter care, nor was there a care plan developed and implemented. Staff interviews revealed that catheter care tasks were not communicated effectively, leading to a lack of documented catheter care.
The facility failed to properly handle and store medications, including not discarding a multidose vial past its use-by date, not disposing of a resident's medication after discharge, and not consistently logging refrigerator temperatures.
The facility failed to assist a resident with cerebellar stroke syndrome in obtaining dental services after experiencing bleeding gums. Despite a care plan and physician's order, no dental appointment was made following the resident's reported oral pain and bleeding gums. The facility did not follow up adequately after the Guardian did not respond to the initial contact attempt.
A resident with lactose intolerance received meals containing cheese due to inaccurate diet documentation. The facility's diet type report did not include the resident's milk allergy, leading to inappropriate meal service.
The facility failed to complete a discharge MDS assessment for a resident and did not document catheter care for another resident, resulting in incomplete clinical records and documentation.
The facility failed to ensure timely infection control training for an MDS Coordinator, who had not completed the required annual training for 2024. The HR Generalist confirmed the lapse, despite the facility's policy mandating yearly infection control education for all permanent nursing staff.
The facility failed to develop and implement care plans for three residents with specific medical needs, including an indwelling catheter, end-of-life care, and an air mattress, despite physician's orders and facility policies requiring individualized care plans.
The facility failed to ensure a timely MDS assessment transmission for a discharged resident with metabolic encephalopathy and major depressive disorder. The required final validation report was over 120 days late, and the facility lacked a policy for MDS final validation reporting.
The facility failed to ensure residents were treated with dignity when residents felt bothered, annoyed, or harassed by other residents' comments and behaviors. Despite staff attempts to redirect inappropriate behavior, the administration was not fully aware of the extent of the issues, leading to continued distress for the affected residents.
A non-verbal resident with severe cognitive impairment was verbally abused by a CNA, who told the resident to 'shut the (expletive) up.' Despite a Dietary Aide witnessing and reporting the incident, the facility's investigation deemed the allegation unsubstantiated due to lack of corroboration and the resident's inability to communicate effectively. The CNA was suspended and later terminated.
The facility failed to ensure a Facility Reported Incident (FRI) was completed and submitted timely to the State Agency (SA) for allegations of abuse. An FRI involving resident-to-resident abuse was submitted late, outside the required timeframes. The facility's policy mandates immediate reporting, but not later than two hours if the alleged violation involves abuse or results in serious bodily injury, and within 24 hours for all other allegations.
The facility failed to thoroughly investigate and document an allegation of verbal abuse by a CNA towards a resident, and did not update the resident's care plan with preventive measures. Additionally, the facility did not report investigation results within the required five working days for two separate incidents.
Improper food storage and kitchen hygiene practices
Penalty
Summary
Food storage and kitchen sanitation practices were not followed when an unopened 8.4 ounce can of Red Bull original, belonging to a facility employee, was found in the refrigerator by the three-compartment sink with no date or label. The Dietary Manager confirmed the item was employee food and stated they had not been aware that employee personal food items were not to be stored with resident food items. The facility policy for nutrition room refrigerators stated that resident refrigerators in LTC and nutrition rooms were reserved for resident food only and that no employee food was to be stored in resident refrigerators. Additional kitchen observations showed a cook on the tray line wearing a black lightning bolt earring that dangled below the right earlobe and measured about one inch in length. The Dietary Manager confirmed the earring was being worn while on tray line and stated jewelry over a quarter of an inch should not be worn in the kitchen. The Cook, a Dietary Aide/Cook, and Dietary Aide #1 were also observed with uncovered sideburns and facial hair, including an uncovered moustache and goatee while preparing a cheese quesadilla on the tray line. In addition, Dietary Aide #2 returned to the kitchen after delivering trays and entered the tray line before washing hands, and the Dietary Manager confirmed hand hygiene was required before returning to the tray line.
Infection Control Lapses During Tube Site Care, Medication Cart Storage, and Housekeeping Tasks
Penalty
Summary
Hand hygiene was not performed during a dressing change for a gastric tube insertion site for one resident who had diagnoses including dysphagia following cerebral infarction and cerebellar stroke syndrome. The resident had an order for complete tube site care every day. During the dressing change, the RN removed the old dressing, cleaned the area around the insertion site, dried the area with dry gauze, and applied a new dressing without performing hand hygiene or changing gloves between removing the old dressing and applying the clean dressing. The RN confirmed hand hygiene and glove change should have occurred between those steps, and the DON stated the correct process was to remove the dressing, perform hand hygiene, don new gloves, and then apply the clean dressing. A staff member's personal belongings were stored in the top drawer of a medication cart on top of tissues intended for resident use. During observation, the top drawer contained a tissue box along with a staff member's cell phone and lip balm. The DON confirmed the items should not have been stored in the medication cart or near items intended for resident use, and the LPN confirmed the personal items belonged to the LPN. The facility policy for medication storage stated areas where drugs were stored would be kept dry, clean, and neat at all times. Housekeeping infection control practices were also not followed when a housekeeper handled a soiled mop pad and then touched other surfaces without hand hygiene. The housekeeper mopped a resident room without gloves, removed the mop pad from the mop handle, placed it in a plastic bag on a housekeeping cart, grabbed the cart handle, opened a binder on the cart, and then touched the nutrition room door handle without performing hand hygiene. The housekeeper confirmed gloves were usually worn when touching soiled mop pads and hand hygiene would be performed after removing gloves. The IP and DON stated hand hygiene was required when going in and out of resident rooms, before and after tasks, and after contact with residents or objects in the resident's environment, and the facility policy stated staff who came into contact directly or indirectly with patients, equipment, or the environment would perform effective hand hygiene practices.
Late Abuse and Neglect Reporting and Incomplete Investigation Reporting
Penalty
Summary
The facility failed to ensure the results of a facility reported incident (FRI) abuse investigation were reported to the State Agency within five working days for Resident #6. Resident #6 was admitted with diagnoses including acquired absence of the left foot and acquired absence of the right leg below the knee. The initial FRI, dated 03/03/2026, documented that the resident attempted to self-transfer, fell, and had a change in mentation afterward, requiring transfer to the emergency room for evaluation and treatment. The initial report stated that a final report with the investigation findings would be completed when the resident returned from the emergency room, but the FRI did not include a final report with the results of the facility investigation. The facility also failed to submit an initial FRI for potential neglect within 24 hours of staff becoming aware of the allegation for Resident #5. Resident #5 was admitted and later readmitted with diagnoses including type 2 diabetes mellitus without complications and presence of an artificial hip joint. The initial FRI, submitted on 03/24/2026 at 7:37 AM, documented that the resident reported to a nurse that night shift CNAs were rough with the resident and refused to take vital signs. The DON, who was also the Abuse Coordinator, confirmed the resident had told a nurse on 03/21/2026 that the CNAs were rough and refused to check vital signs, and that the nurse emailed the DON and ADON around 3:00 AM on 03/23/2026. The DON/AC stated the allegation should have been reported immediately and that the initial FRI was submitted beyond the required timeframe; the alleged perpetrators were not suspended immediately due to the delay in staff reporting.
Personal Possession Removed Without Resident Permission
Penalty
Summary
The facility failed to ensure staff followed its policy related to inventorying residents’ personal belongings and failed to ensure a resident was allowed to retain and use personal possessions when a fish tank was removed from Resident #12’s room without the resident’s permission and placed in a common area. Resident #12 was admitted with diagnoses including rheumatoid arthritis and major depressive disorder. The resident stated that a staff member had removed the aquarium from the room, and later pointed out a large cylindrical fish tank in the activities room that was unplugged, secured to the wall, and contained faux fish. Resident #12 explained that the fish tank had previously belonged to the resident’s roommate, Resident #26, who had died, and that Resident #26’s family member had given the tank to Resident #12 because the resident loved it. The resident said the tank had been kept in the room and was usually turned off because the noise bothered other residents. An Activity Participation Note documented that Resident #12 was upset about the fish tank, that the AD told the resident the facility set the rules and the room had too many belongings to fit the tank, and that the tank was placed in the common area for everyone to enjoy. The note also documented the resident was refusing to participate in activities because of this. The SW, US, DON, and AD each described the fish tank and the circumstances surrounding it. The SW and DON confirmed the tank had remained in Resident #12’s room after Resident #26 passed away and that staff had discussed the tank with Resident #12. The AD stated maintenance removed the tank at the AD’s request, and the tank was later found in the activities room. Staff denied having documentation of Resident #12 taking possession of the tank, the disposition of Resident #26’s belongings after death, any conversation with the resident about safety concerns, or any offer of alternatives. The facility policy required residents to be allowed to retain and use personal items unless the item presented a safety risk, created an infection control concern, was prohibited by law, or interfered with care or treatment, and required inventorying belongings on admission and after death.
Late MDS Submission After Resident Death
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) 3.0 assessment was transmitted timely for one discharged resident. Resident #26 was admitted with diagnoses including unspecified dementia with behavioral disturbances, major depressive disorder, and age-related physical debility. A progress note documented that the resident passed away while in the facility, and the MDS assessment for the resident documented in Section A that the resident died in the facility. The MDS assessment was completed by the MDS RN after the resident's death, but it was not submitted to CMS until more than a month later. The submission validation report stated the record was submitted late and should have been transmitted within 14 days of the resident's death. The MDS RN confirmed the assessment had been completed after the resident died and acknowledged that it should have been submitted within 14 days. The MDS RN also stated the facility did not have a policy related to MDS submission validation reporting and relied on the RAI Manual for guidance.
Controlled Medication Not Documented at Time of Administration
Penalty
Summary
The facility failed to ensure that a controlled medication was documented in the controlled drug record at the time it was administered for Resident #5. Resident #5 was admitted with diagnoses including anxiety disorder, unspecified, and borderline personality disorder. The medication order and June 2026 MAR documented Ativan oral tablet 1 mg to be given by mouth three times a day for fidgeting, agitation, and restlessness related to anxiety disorder. On 06/11/2026 at 9:39 AM, during observation of the narcotic drawer in the medication cart with the DON, an LPN retrieved the controlled substance log and stated the medication needed to be documented in the log. At 9:40 AM, the LPN confirmed Ativan had been administered to Resident #5 at 9:31 AM but had not been documented in the controlled substance log and the current count had not been recorded. At 9:41 AM, the DON stated that a controlled substance such as Ativan should have been documented in the controlled substance log at the time it was administered so the medication count would be accurate and the nurse administering it could ensure the current count was accurate prior to administration. The facility policy titled Medication Administration, reviewed 05/01/2026, stated documentation of medication administration would be completed after administering the medication to the resident.
Missing Documented Consent for Flu Vaccinations
Penalty
Summary
The facility failed to provide documented evidence that residents and/or their representatives were given the opportunity to change their decision regarding acceptance or declination of the influenza vaccine before it was administered to 2 of 5 residents sampled, Residents #4 and #23. Both residents had a Record of Vaccination Acceptance and Declination Form signed by their representatives earlier in the year, documenting that the provider notified the resident and/or responsible party about CDC-recommended vaccinations, discussed risks and benefits, and noted that the resident and/or representative could change their mind at any time. Resident #4 was admitted with aphasia following cerebral infarction, and Resident #23 was admitted with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. For both residents, an Influenza Vaccination Consent and Documentation form showed the flu vaccine was administered later in the year. The forms included contraindication screening questions and a statement that the resident/representative had been given the opportunity to decline and had consented to the vaccine, but the patient signature line and parent/guardian signature lines were left blank. The forms lacked documented evidence that the screening was completed with the resident/representative and that consent was obtained at the time of administration. During interview, the DON and IP acknowledged the forms did not show consent at administration or that the resident/representative was given the opportunity to change their mind. The DON stated that when a resident was not their own responsible party, staff usually administered vaccines based on the earlier acceptance form because responses from representatives or POAs were not often received, although the DON expected staff to obtain informed consent and complete an individual consent form prior to each vaccine.
Missing documented consent for COVID-19 vaccine administration
Penalty
Summary
The facility failed to provide documented evidence that residents and/or their representatives were given the opportunity to change their decision regarding acceptance or declination of the COVID-19 vaccine before the vaccine was administered to two sampled residents. Resident #24, who was admitted with diagnoses including other sequelae of cerebral infarction and severe vascular dementia with anxiety, had a Record of Vaccination Acceptance and Declination Form signed on 06/04/2025 indicating the COVID-19 vaccine was accepted and that the resident and/or representative could change their mind at any time. However, the facility’s Vaccination Administration Forms showed the vaccine was administered on 01/17/2026 and 04/22/2026 without documented evidence that consent was obtained at the time of administration or that staff verified whether the resident or representative still wanted the vaccine. Resident #4, who was admitted with aphasia following cerebral infarction, had a Record of Vaccination Acceptance and Declination Form signed by the resident’s representative on 07/24/2025 documenting acceptance of the COVID-19 vaccine and stating the resident and/or representative could change their mind at any time. A facility Vaccination Administration Form documented that the vaccine was administered on 01/16/2026, but the form lacked documented evidence that consent was obtained at the time of administration or that staff verified whether the resident or representative had changed their decision before the vaccine was given. During interview on 06/11/2026, the DON and Infection Preventionist stated the facility reviewed WebIZ to determine vaccine eligibility, reviewed eligibility on admission and at least annually, and used the Record of Vaccination Acceptance or Declination Form to identify which vaccines residents were interested in. They stated staff were to ask the resident and/or representative again when the vaccine was due and complete a separate form at the time of administration. The DON and IP acknowledged the administration forms for Residents #4 and #24 lacked documented evidence of consent at the time of administration and lacked documentation that the resident or representative was given the opportunity to change their mind. The DON stated the expectation was that informed consent would be obtained before each vaccine, including verbal consent by phone when applicable, and acknowledged that failure to obtain consent at the time of administration denied the resident/representative the opportunity to decline the vaccine.
Missed Annual Elder Abuse Prevention Training for Contractor
Penalty
Summary
The facility failed to ensure elder abuse prevention training was completed timely for 1 of 20 sampled employees, Employee #10, a Speech Therapist Contractor hired on 05/24/2018. The personnel record showed elder abuse training was completed on 01/20/2025, but there was no documentation that annual elder abuse prevention training had been completed in 2026. On 06/11/2026 at 7:52 AM, the Administrator confirmed that Employee #10 had not completed the required annual elder abuse prevention training for 2026, although it should have been completed. The facility policy titled, Abuse/Neglect Prevention and Prohibition Long Term Care, reviewed 05/12/2026, stated employees were to complete abuse and neglect prevention training upon employment and annually thereafter.
Incomplete Posted Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the posted nurse staffing information included the actual hours worked per shift for licensed and unlicensed nursing staff directly responsible for resident care. On 06/08/2026, 06/09/2026, 06/10/2026, and 06/11/2026, the posted staffing data did not include the actual hours worked per shift by licensed and unlicensed staff. During an interview on 06/11/2026 at 9:19 AM, the DON stated she was unaware of the requirement to include actual hours worked on the posted nurse staffing data and confirmed that the facility's posting did not include those hours.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) 3.0 assessments for two residents. For one resident with a diagnosis of major depressive disorder, the quarterly MDS assessment indicated the use of an antidepressant within the seven-day look-back period. However, a review of physician orders revealed that no antidepressant medication was currently ordered or administered for this resident. The Director of Nursing confirmed that the resident had not been receiving an antidepressant at the time of the assessment, indicating an incorrect MDS entry. For another resident with multiple diagnoses including aphasia, intellectual disabilities, and a history of falls, the quarterly MDS assessment documented daily use of a floor mat alarm during the look-back period. Physician orders did not include any documentation for a floor mat alarm, and direct observation confirmed the absence of such equipment in the resident's room. The Director of Nursing further confirmed that the facility did not possess or use floor mat alarms, and acknowledged that the MDS assessment had been coded incorrectly for this resident as well.
Failure to Obtain Order and Correctly Apply Heel Boots
Penalty
Summary
The facility failed to obtain a physician's order prior to the application of pressure redistribution/heel protector boots for a resident with multiple diagnoses, including dementia, foot drop, and lower leg pain. Observations on multiple occasions revealed that the resident was resting in bed with heel boots placed under their feet, but the boots were not fastened and the resident's heels were not positioned over the pressure redistribution opening as required. The clinical record lacked an order for the use and monitoring of heel boots, and there was no documentation of heel assessments or monitoring for pressure injuries or deep tissue injuries related to the use of the boots. Interviews with nursing staff and the DON confirmed that both nurses and CNAs applied the heel boots without a physician's order and that the boots were not correctly applied, as the resident's heels were not aligned with the opening. Staff explained that the boots were left unfastened due to the resident's sensitivity and preference, but acknowledged that an order was required and that the boots should have been properly positioned to prevent pressure injuries. Facility policy required orders for all equipment used in resident care and specified correct application of pressure redistribution devices, which was not followed in this case.
Failure to Complete Timely Behavioral Health Training for New Staff
Penalty
Summary
The facility failed to ensure that initial behavioral health care training was completed in a timely manner according to its own policy for one employee. Specifically, a Registered Nurse hired as the Minimum Data Set 3.0 nurse did not have documented evidence of completing behavioral health care training within 40 hours of their start date, as required by the facility's policy. This was confirmed through personnel record review and interviews with the Human Resources Director, who acknowledged the training had not been completed, and the Administrator, who was unaware of the requirement. The facility's policy, revised on 06/28/2023, clearly states that new employees must complete behavioral health training within 40 hours of starting employment.
Failure to Develop Care Plan for Resident's Edema
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with bilateral lower extremity edema, which was necessary to address the side effects and required monitoring for the condition. The resident, who was admitted and readmitted with a diagnosis of bilateral primary osteoarthritis of the knee, reported swelling in both legs and was not wearing compression stockings. Despite a physician's order for compression stockings as needed for occasional swelling, the resident's clinical record lacked a documented care plan for managing the edema associated with their osteoarthritis. The Director of Nursing confirmed the absence of a care plan for the resident's condition and acknowledged that the compression stockings should have been included as an intervention in the care plan. The facility's policy mandates an individualized, interdisciplinary plan of care for all residents, tailored to their needs and goals, which was not adhered to in this case. This oversight had the potential to result in adverse health outcomes due to staff being unaware of the necessary monitoring for the resident's leg swelling.
Failure to Revise Care Plans for Psychotropic Medication and Fall Prevention
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised to include physician-identified behaviors for the administration of psychotropic medication for one resident and new interventions for the prevention of falls for two other residents. For the first resident, the care plans did not reflect the paranoid ideation behavior indicated in the physician's orders for psychotropic medications. The Director of Nursing (DON) confirmed that the care plans lacked documentation of this behavior, which was necessary for the administration of the prescribed medications. For the second resident, the facility did not update the care plan with new interventions after the resident experienced a fall. The resident had a history of impulsive behavior, poor safety awareness, and confusion, which contributed to the fall. Despite the interdisciplinary team's (IDT) suggestion to use grip strips as a preventive measure, the facility failed to implement this intervention, and the care plan was not revised to include it. The third resident also experienced multiple falls, and the facility did not adequately update the care plan with effective interventions. The resident had impulse control issues and often attempted to self-transfer, leading to falls. Although a trapeze was considered as an intervention, it was deemed inappropriate by the therapy team, and no alternative interventions were documented in the care plan. The facility's failure to revise care plans and implement appropriate interventions contributed to the ongoing risk of falls for these residents.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for two residents following incidents of falls. Resident #23, who has a history of dementia and major depressive disorder, experienced a fall from the bed on 10/08/2024 due to impulsivity and poor safety awareness. Despite the interdisciplinary team's recommendation to apply grip strips to the floor to prevent further falls, this intervention was not implemented, and the resident's care plan was not updated with new interventions. Additionally, a required Morse scale evaluation was not completed post-fall to assess the resident's risk and potential decline. Resident #25, diagnosed with major depressive disorder, experienced multiple unwitnessed falls in September and October 2024. The resident's falls were attributed to impulsivity and poor safety awareness, with the resident often attempting to self-transfer without assistance. Although a bed alarm was placed after one fall, the care plan was not updated with effective interventions following the falls on 09/14/2024 and 09/25/2024. A proposed intervention involving a trapeze was deemed inappropriate by therapy staff, and no alternative interventions were suggested or implemented. The facility's policy on falls and fall prevention, revised in 05/2024, requires that extra measures be added to the care plan for fall prevention and that a Morse scale evaluation be completed post-fall. However, these requirements were not met for the residents involved, indicating a failure to adhere to established protocols for fall prevention and risk assessment.
Failure to Complete Timely Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) received their annual performance evaluations in a timely manner. Employee #3, hired as an Activity Director/CNA, had their last evaluation completed in May 2023, but lacked documentation for May 2024. Employee #8, hired as a CNA, had their last evaluation in April 2023, with no documentation for April 2024. Employee #9, also a CNA, had their last evaluation in June 2023, with no documentation for June 2024. The Human Resources Director confirmed that the annual performance evaluations for these employees were not completed as required by the facility's policy, which mandates annual evaluations by the anniversary date of hire.
Medication Unavailability and Lack of Procurement Procedure
Penalty
Summary
The facility failed to ensure that ordered medications were available for a resident, specifically Restasis Ophthalmic Emulsion, which was prescribed for cataract inflammation. The medication was not administered on multiple occasions as it was unavailable in the facility and on order from the pharmacy. The Medication Administration Record (MAR) for the resident documented the absence of the medication over several days, with notes indicating that the medication was on order and awaiting delivery. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) confirmed that the medication had been unavailable since a specific date, and the DON had contacted the pharmacy multiple times to request a refill. Additionally, the facility lacked a documented policy or procedure for the safe procurement of drugs and biologicals, as confirmed by the Administrator and the DON. The Consultant Pharmacist Agreement indicated that the consultant pharmacist was responsible for assisting with the implementation of such policies and procedures.
Failure to Document Specific Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that behaviors monitored were associated with the specific condition indicated by the physician for the use of psychotropic medications for one of the sampled residents. Resident #2, who was diagnosed with major depressive disorder and vascular dementia, was prescribed Seroquel and Cymbalta for low mood, anxiety, and paranoid ideation. However, the behavior monitoring in the electronic Medication Administration Record (eMAR) was not personalized to the specific psychotropic medication, and there was no documented evidence of the behaviors exhibited by the resident on a specific date. The Director of Nursing (DON) confirmed that the behavior monitoring was not related to the behaviors identified for the administration of the psychotropic medications. Additionally, the facility did not ensure that physician-ordered psychotropic medications had a specific condition documented for indication of use associated with the diagnoses for five other sampled residents. These residents were prescribed various psychotropic medications for conditions such as major depressive disorder and unspecified psychosis. The DON explained that physician orders for psychotropic medications were required to include the specific behaviors and/or symptoms the medication was ordered for, but the physician had not been identifying specific behaviors related to the administration of the psychotropic medications. The facility's policy on psychotropic medications required daily monitoring to include the presence and frequency of resident-specific targeted behaviors. However, the interdisciplinary team did not ensure that the lowest possible effective dose was used in managing identified behaviors, and the provider's order did not include the reason for the psychotropic being ordered. This lack of specific documentation and monitoring led to the deficiency identified by the surveyors.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 6.9% error rate. This was identified through observation, interview, clinical record review, and document review. Specifically, there were 29 medication administration opportunities, and two errors were noted. One of the errors involved a registered nurse (RN) who did not administer Metoprolol to a resident during the morning medication pass. The RN initially prepared the medications but forgot to include Metoprolol in the medication cup due to nervousness about being observed. The resident involved had a medical history that included heart failure and dry eye syndrome. The physician's orders for the resident included Restasis Ophthalmic Emulsion for eye inflammation and Metoprolol for heart failure and tachycardia. The RN realized the omission after being asked to verify the contents of the medication cup and subsequently administered the Metoprolol. The facility's Director of Nursing (DON) confirmed that the expectation was for nursing staff to verify and administer medications according to physician orders, and that omissions constituted medication errors.
Medication Administration Error for Heart Failure Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of Metoprolol Tartrate. The resident, who was admitted with a diagnosis of unspecified heart failure, had a physician's order for Metoprolol Tartrate 12.5 mg to be administered twice daily, with specific parameters to hold the medication if the blood pressure was below 90/50 or the heart rate was below 50. During a medication pass observation, a registered nurse (RN) prepared the medications for the resident but failed to include the Metoprolol in the medication cup before attempting to administer it. The RN realized the omission after being prompted to verify the contents of the medication cup. The RN attributed the error to nervousness due to being observed. The Director of Nursing (DON) confirmed that the facility's policy required medications to be administered according to physician's orders and that omissions constituted medication errors. The facility's policy and the drug information for Metoprolol Tartrate emphasized the importance of administering the medication as prescribed to manage hypertension and heart failure effectively.
Documentation and Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation of psychotropic behavior monitoring for six residents, as required by physician orders. These residents, diagnosed with various mental health conditions such as major depressive disorder and dementia, had blank spaces in their Behavioral Health (BH) Records for specific dates, indicating that behavior monitoring was not documented during certain day shifts. The Director of Nursing (DON) confirmed the omissions, attributing them to possible forgetfulness by the nursing staff. Additionally, the facility did not maintain accurate medication administration records for one resident. This resident was supposed to receive Restasis Ophthalmic Emulsion eye drops, but the medication was unavailable in the facility from a certain date. Despite this, the Medication Administration Record (MAR) inaccurately documented that the medication was administered during the morning medication pass on several days. The DON acknowledged the error, explaining that the medication was not available and had been documented as administered in error. The facility's policy on medication administration emphasizes the importance of the seven rights, including right documentation, which was not adhered to in this case. The DON and a Registered Nurse (RN) confirmed the unavailability of the medication and the incorrect documentation, highlighting a lapse in following the facility's medication administration procedures.
Failure to Provide Restorative Nursing Program
Penalty
Summary
The facility failed to ensure the Restorative Nursing Program (RNP) was provided to 13 residents in need of restorative nursing services. The deficiency was identified through observation, interview, clinical record review, and document review. The Restorative Nursing Aide (RNA) confirmed that the RNP had not been active since January 2024 due to staffing changes, and the program only resumed when the RNA was hired in April 2024. The Director of Nursing (DON) also confirmed that no restorative care was provided to residents from January to April 2024, which led to a lapse in maintaining residents' baseline physical abilities. The report detailed specific cases of residents who were affected by the lack of restorative nursing services. For instance, Resident #1, who had diagnoses including generalized anxiety disorder and muscle contracture, lacked documented evidence of participation in the RNP. Similarly, Resident #2, with chronic respiratory failure, and Resident #3, with intracranial injury and muscle contracture, also lacked documentation of RNP participation. The RNA admitted that there was no official list of residents in the RNP, and the RNA had to create a handwritten list of residents to work with. The DON and RNA both acknowledged the failure to document and provide necessary restorative care. The DON admitted to misunderstanding what constituted restorative nursing, believing that activities like showering and brace assistance were sufficient. However, the clinical records of the residents requiring RNP services lacked documented evidence of these activities being part of the RNP. The Administrator also admitted that the facility failed to execute the plan to have more than one person oversee the RNP when the LPN left the position in January 2024, leading to the oversight.
Failure to Maintain Restorative Nursing Program and Properly Investigate Abuse
Penalty
Summary
The Administrator failed to ensure a Restorative Nursing Program (RNP) was maintained for residents with the potential to participate. The Restorative Nursing Aide (RNA) confirmed that the RNP had not been active since January 2024 due to the Licensed Practical Nurse (LPN) responsible for restorative care changing job duties because of short staffing. The Director of Nursing (DON) corroborated that from January 8, 2024, to April 8, 2024, no restorative care was provided. The Administrator admitted that the plan to have more than one person oversee the RNP was not executed, leading to the program being neglected. The Abuse Committee failed to properly investigate allegations of employee-to-resident abuse by not applying the correct definition of abuse as per federal regulations. A Facility Reported Incident (FRI) involving an employee allegedly verbally and physically abusing a resident was unsubstantiated by the facility, despite the employee admitting responsibility. The Administrator and the Abuse Committee incorrectly believed that abuse was only substantiated if the resident experienced injury, harm, pain, or mental anguish. This misunderstanding led to inappropriate investigations of abuse allegations.
Failure to Ensure QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that 10 out of 20 sampled staff members received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. The personnel records of employees, including the Director of Nursing, Registered Dietitian, Certified Nursing Assistants, Registered Nurse, Licensed Practical Nurse, Dietary Aides/Cooks, and Housekeeper, lacked documented evidence of completed QAPI training. This deficiency was identified during a review of personnel records, interviews, and document reviews conducted by surveyors. The Administrator acknowledged that the issue with QAPI training had been identified in previous surveys and that some staff had not yet completed the training. The Administrator also mentioned that QAPI training had not been part of the onboarding employee orientation but would be included moving forward. The Risk Manager confirmed that it was their responsibility to ensure QAPI training was completed and acknowledged that 10 of the 20 sampled employees had not yet completed the required training. The facility's policy on QAPI, reviewed on 10/11/2023, stated that facility-wide training would be conducted to inform all employees about the QAPI plan.
Failure to Recognize and Address Abuse; Inadequate Restorative Nursing Program
Penalty
Summary
The facility's Abuse Committee, including the Director of Nursing (DON), failed to recognize and identify actual employee-to-resident verbal and physical abuse towards a resident. This incident involved a Certified Nursing Assistant (CNA) who was observed slapping a non-verbal, quadriplegic resident on the hand and verbally threatening the resident. Despite multiple staff members witnessing and reporting the abuse, the facility's investigation concluded that the incident did not meet the criteria for abuse because there were no physical signs of injury on the resident. The Administrator and DON both failed to acknowledge the psychological impact of the abuse, focusing solely on the absence of physical harm. The report also highlights a deficiency in the facility's Restorative Nursing Program (RNP). The DON admitted to a lack of knowledge and skills needed to manage the program effectively. From early January to early April, the facility did not provide restorative care to residents due to staffing changes. The newly hired Restorative Nursing Aide (RNA) began working without a clear list of residents requiring restorative care, and there was no proper documentation of the care provided. The DON was unaware of the residents' participation in the RNP and did not know where to access relevant physical therapy notes. The facility's policies on abuse prevention and restorative nursing were not followed. The abuse policy required immediate suspension of the caregiver, notification of family or guardians, and reporting to law enforcement and state authorities, none of which were adequately executed. Similarly, the RNP policy required daily documentation and specific care plans for each resident, which were not maintained. These failures indicate a significant lapse in the facility's adherence to its own policies and procedures, leading to deficiencies in resident care and safety.
Failure to Protect Resident's Right to Dignity and Respect
Penalty
Summary
The facility failed to ensure a resident's right to be treated with respect and dignity was protected when a care plan was updated to include sexual behaviors of the resident without evidence or assessment of a change in the resident's baseline. This occurred after facility staff observed physical and verbal abuse by a Certified Nursing Assistant (CNA) toward a cognitively impaired, non-verbal resident. The resident, who had limited fine motor skills and was non-verbal, had a care plan initiated as part of their clinical record without any prior history of such behaviors or a proper assessment to substantiate the change. The incident began when a Dietary Aide overheard a CNA telling the resident, 'I told you I would slap you if you did that again,' and alleged that the resident was touching the CNA's breasts. The facility's investigation into the incident was unsubstantiated, but the care plan was still updated to reflect inappropriate sexual behaviors. The resident's guardian and other staff members questioned the validity of the claim, given the resident's limited mobility and non-verbal status. The resident's guardian expressed disbelief and concern over the staff's abusive language and actions toward the resident. Multiple witness statements and assessments indicated that the resident had not exhibited any sexual behaviors prior to this incident. The facility's policies on abuse prevention and care planning were not followed, as the care plan was updated without proper assessment or evidence. The Administrator and MDS Coordinator acknowledged that the care plan was inaccurate and that the resident's mental and physical abilities had remained unchanged. Despite this, the care plan was still updated to include inappropriate sexual behaviors, violating the resident's right to dignity and respect.
Failure to Protect Resident from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse by a Certified Nursing Assistant (CNA). Resident #3, who was non-verbal and had limited mobility due to quadriplegia, was allegedly slapped on the hand by CNA1 after the resident brushed the CNA's breast. The incident was witnessed by the Food Services Supervisor, who reported that CNA1 told the resident, 'I told you I would slap you if you did that again,' and then slapped the resident's hand. The facility's investigation into the incident was unsubstantiated, citing a lack of negative psychosocial outcomes for the resident and no physical signs of injury. The resident's Guardian expressed disbelief that Resident #3 could have touched the CNA inappropriately, given the resident's limited mobility and non-verbal status. The Guardian also noted that the resident had no history of such behavior. The facility's Care Plan for Resident #3 indicated a risk for victimization due to cognitive impairment, communication barriers, and physical limitations. Despite this, the facility did not take disciplinary action against CNA1, and the Administrator did not refer the CNA to the Board of Nursing or conduct a further investigation. Multiple staff members, including the Food Services Supervisor and other CNAs, provided statements corroborating the incident. The Licensed Social Worker and Director of Nursing both acknowledged that abuse does not require physical injury to be substantiated. However, the Administrator and DON concluded that the incident did not meet the facility's definition of abuse, as there were no physical signs of injury. The facility's policies on abuse prevention, resident rights, and psychosocial needs emphasize the importance of protecting residents from all forms of abuse, yet these policies were not effectively enforced in this case.
Failure to Implement Abuse Policies
Penalty
Summary
The facility failed to implement its abuse policies regarding identification, investigation, protection, and reporting for an allegation of verbal and physical abuse toward a resident by a Certified Nursing Assistant (CNA). The incident involved a resident who was non-verbal, quadriplegic, and had cognitive impairments. The resident was allegedly slapped on the hand by a CNA after the resident brushed their hand against the CNA's breast. The incident was witnessed by a Food Services Supervisor who reported it to the Charge Nurse immediately. Despite the report, the facility did not take appropriate disciplinary action against the CNA, and the incident was unsubstantiated due to a lack of physical injury on the resident. The facility's investigation included statements from various staff members, including the Food Services Supervisor, other CNAs, and the Administrator. The Food Services Supervisor described the CNA's attitude as frustrated and observed the CNA slap the resident's hand and verbally threaten the resident. Other staff members also overheard the CNA telling the resident to stop touching the CNA's breasts. The Administrator and Director of Nursing (DON) were informed of the incident, but the Administrator concluded that the incident did not meet the criteria for abuse as defined in the State Operations Manual (SOM) because there were no physical signs of injury on the resident. The facility's policy on abuse prevention and prohibition was not followed. The policy required the formation of an Abuse Investigation Team to interview witnesses, gather statements, and make a recommendation based on the information collected. However, the Administrator did not refer the CNA to the Board of Nursing or investigate the allegation further. The Licensed Social Worker (LSW) monitored the resident for three days for any negative psychosocial outcomes but determined no further monitoring was necessary. The facility's failure to follow its own policies and procedures resulted in the deficiency noted in the report.
Failure to Obtain Informed Consent for Air Mattress Use
Penalty
Summary
The facility failed to ensure that a resident's Guardian gave informed consent prior to placing an air mattress on top of a bariatric bed for a resident. The resident, who was quadriplegic and required assistance with all Activities of Daily Living (ADL), was observed in a geri-chair next to a bariatric bed with an air mattress. The clinical record for the resident lacked a care plan addressing the air mattress and did not contain documented evidence that the risks and benefits were explained to the resident's Guardian. Additionally, there was no assessment for the risk of entrapment and restraint. The Director of Nursing (DON) confirmed that the air mattress was considered a restraint and that the facility needed to document interventions attempted prior to its use, assess the resident for risk of entrapment, and review the risks and benefits with the Guardian. The DON and the Minimum Data Set (MDS) Coordinator both confirmed that informed consent was not obtained from the resident's Guardian before placing the air mattress on the bed. The facility's policy on Mobility Devices and Physical Restraints required an assessment, monitoring, a physician's order, consents, and a care plan before using any physical restraint, which was not followed in this case.
Failure to Report Fall with Serious Injury
Penalty
Summary
The facility failed to report a fall resulting in serious bodily injury to the State Agency (SA) for one resident. Resident #7, who had diagnoses including unspecified dementia with behavioral disturbances and wandering, fell in the dining area and struck the back of their head on a door frame. The resident lost consciousness for five seconds and was transferred to the emergency room (ER) for further assessment. Despite the severity of the incident, the Administrator did not report the fall to the SA, believing it did not meet the definition of serious bodily injury. The Director of Nursing (DON) confirmed that the incident should have been reported as it involved a head injury, loss of consciousness, and transfer to the ER, but the DON also failed to report it to the SA. The facility's policies on Falls and Fall Prevention and Abuse Prevention and Prohibition both required that falls with significant injury be reported to the SA. The policies defined significant injury as one requiring the resident to be sent to the ER, clinic, or x-ray department for medical attention. Despite these policies, the incident involving Resident #7 was not reported, indicating a failure in adhering to the facility's own reporting requirements. The Administrator and DON both acknowledged the oversight, confirming that the incident met the criteria for reporting but was not reported as required.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide a discharge notification to the State Long Term Care Ombudsman for Resident #26. Resident #26, who had diagnoses including type II diabetes mellitus with other specified complications and chronic obstructive pulmonary disease, was admitted to the facility on an unspecified date. On 03/03/2024, the resident exhibited slurred speech and altered mental status and was subsequently transferred to the hospital. The resident was discharged from the facility on 03/04/2024. However, the clinical record lacked documented evidence that a notification of discharge was provided to the State Long Term Care Ombudsman's office. The Minimum Data Set (MDS) Registered Nurse confirmed that it was their responsibility to notify the Ombudsman's office of discharges and acknowledged that the notification for Resident #26 had not been submitted, despite the facility's policy requiring such notification.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. Resident #2's MDS assessment inaccurately documented the presence of an indwelling catheter, which was confirmed to be an error by the MDS Coordinator. Resident #2's clinical record lacked any evidence of an indwelling catheter, and the resident denied having one during an interview. This discrepancy was acknowledged by the MDS Coordinator, who admitted the mistake in the documentation. Resident #15's MDS assessment incorrectly documented the use of an antipsychotic medication and the use of bed rails as physical restraints. The resident was actually receiving Depakote, an anticonvulsant, for behavioral disturbances related to vascular dementia, not an antipsychotic. Additionally, the bed rails were used for mobility and safety, not as restraints, as confirmed by the MDS Coordinator. Resident #17's MDS assessment inaccurately documented the use of an anticoagulant medication. The resident was taking Clopidogrel, an antiplatelet agent, not an anticoagulant. The MDS Coordinator admitted the error, stating that Clopidogrel should have been documented as an antiplatelet according to the Resident Assessment Instrument (RAI) Manual.
Failure to Follow Physician's Orders for Insulin Therapy
Penalty
Summary
The facility failed to follow physician's orders for insulin therapy for two residents diagnosed with type II diabetes mellitus. Resident #9 had a physician's order to administer NovoLOG Insulin FlexPen based on a sliding scale and to notify the physician if blood sugar levels exceeded 400. On two occasions, the resident's blood sugar levels were over 400, and although the correct insulin dosage was administered, there was no documented evidence that the physician was notified as required by the order. Resident #13 had a similar issue with HumaLOG Insulin KwikPen. The resident's blood sugar levels exceeded 400 multiple times over several months, and while the correct insulin dosages were administered, there was no documented evidence that the physician was notified on any of these occasions. The physician's orders explicitly required notification for blood sugar levels over 400, but this was not followed. The Director of Nursing (DON) confirmed the lack of documentation and acknowledged that it was the facility's expectation for nurses to notify the physician and document the notification in the resident's record. The facility's policy also required such notifications, emphasizing the importance of physician awareness to manage potential complications like diabetic ketoacidosis or to adjust treatment plans as necessary.
Failure to Assess Air Mattress for Entrapment and Restraint
Penalty
Summary
The facility failed to assess an air mattress for entrapment and restraint for a resident diagnosed with multiple conditions including quadriplegia, dementia, and anxiety. The resident's clinical record lacked a care plan addressing the air mattress, and there was no documented evidence that the risks and benefits were explained to the resident's guardian. Additionally, the resident had not been assessed for the risk of entrapment and restraint. A physician's order was in place for the air mattress to prevent skin breakdown, but the necessary assessments and consents were not completed. The Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator confirmed that the air mattress was considered a restraint and that the facility's policy required an assessment, consents, and a care plan before its use. The DON acknowledged that the air mattress could pose a suffocation risk if the resident rolled into the air barriers. The MDS Coordinator also confirmed that the required assessments and consents were not completed, and the risks and benefits were not reviewed with the resident's guardian. The facility's policy on mobility devices and physical restraints mandated these steps, but they were not followed in this case.
Failure to Ensure Proper Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper care and documentation for a resident with an indwelling catheter. Specifically, Resident #19, who was admitted with diagnoses including unspecified sequelae of cerebral infarction and schizoaffective disorder, did not have physician orders for ongoing catheter care, nor was there a care plan developed and implemented for the catheter. The clinical record lacked evidence of catheter care documentation, and the necessary tasks were not populated in the Treatment Administration Record (TAR) due to the absence of physician orders. Interviews with staff, including a CNA, RN, and the MDS Coordinator, revealed that catheter care tasks were typically communicated through the electronic medical record and during shift changes. However, it was discovered that Resident #19's catheter care was not documented because the tasks were not generated in the TAR until several days after the catheter was inserted. The facility's policies on indwelling urinary catheter maintenance and standards of care were not followed, as evidenced by the lack of documented catheter care and an updated care plan for the resident.
Medication Handling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper handling and storage of medications, leading to several deficiencies. During an inspection of the medication storage room, a multidose vial of tuberculin purified protein derivative was found in the refrigerator past its use-by date. The vial, which should have been discarded 28 days after opening, was still present, and the Director of Nursing (DON) confirmed that it should have been discarded earlier. Additionally, an unopened box containing a suprep bowel preparation kit belonging to a resident who no longer resided in the facility was found in a cabinet. The medication should have been destroyed upon the resident's discharge or expiration, but it was not. The DON confirmed that the medication should have been disposed of timely according to the facility's policy. Furthermore, the facility failed to consistently log the temperature of the refrigerator containing medications. The temperature log for two months showed missing entries for several days, indicating that the temperature was not monitored and recorded daily as required. The DON confirmed that the floor nurse was responsible for checking and logging the refrigerator temperature daily, and acknowledged the importance of this task to ensure the safety and efficacy of stored medications. The facility's policy required maintaining a daily log of refrigerator temperatures, but this was not adhered to, leading to potential risks of medication spoilage.
Failure to Assist Resident in Obtaining Dental Services
Penalty
Summary
The facility failed to assist a resident in obtaining dental services after the resident experienced bleeding gums. Resident #10, who was admitted with a diagnosis of cerebellar stroke syndrome, had a care plan that included coordinating dental care due to oral health problems. Despite a physician's order allowing the facility to arrange dental consultations and a care plan intervention to coordinate dental care, the facility did not ensure a dental appointment was made. On 01/10/2024, a CNA observed the resident experiencing oral pain, and an attempt was made to inform the Guardian to schedule a dentist appointment. However, no further documented attempts were made after the Guardian did not respond to the initial contact attempt until 04/10/2024, when the Guardian requested a follow-up dentist appointment. The resident's progress notes indicated that on 02/20/2024, the resident had a large amount of plaque and bleeding gums during oral care. Despite the resident's ongoing dental issues and the care plan's directive, the facility did not follow up adequately to ensure the resident received the necessary dental care. Interviews with the CNA and Social Worker confirmed that the last known attempt to notify the Guardian was on 01/10/2024, and no further actions were taken until the Guardian's response on 04/10/2024. The facility's policy on dental services, which mandates assisting residents in obtaining routine and emergency dental care, was not adhered to in this case.
Failure to Accommodate Lactose Intolerance
Penalty
Summary
The facility failed to accommodate a resident's lactose intolerance, leading to the resident receiving meals containing cheese. Resident #17, diagnosed with lactose intolerance, reported receiving cheese on multiple occasions, including on an egg and sausage bake for breakfast. The resident's physician's orders and comprehensive care plan documented the need for dairy-free products and noted episodes of diarrhea related to lactose intolerance. However, the diet type report used by the kitchen did not include the resident's allergy to milk products. The Dietary Manager confirmed that the diet type report lacked documentation of the resident's allergies, despite having a diet order and communication form indicating a milk allergy. The Minimum Data Set (MDS) Coordinator acknowledged that the diet order and communication form were inaccurate, as they only indicated no milk instead of no milk products. This discrepancy led to the resident receiving inappropriate meals that did not adhere to their dietary restrictions.
Incomplete Clinical Records and Documentation of Care
Penalty
Summary
The facility failed to ensure a resident's clinical record was complete when a Minimum Data Set (MDS) assessment was not completed for a resident upon discharge. Resident #22, who was admitted with diagnoses including metabolic encephalopathy and major depressive disorder, was discharged from the facility, but the clinical record lacked a discharge MDS assessment. The MDS Coordinator confirmed that the required MDS assessment was not submitted to the Centers for Medicare and Medicaid Services (CMS) within the mandated timeframe, resulting in an incomplete and inaccurate clinical record for Resident #22. Additionally, the facility lacked a policy related to MDS final validation reporting. The facility also failed to document care provided related to a resident's indwelling catheter. Resident #19, admitted with diagnoses including unspecified sequelae of cerebral infarction and schizoaffective disorder, had a physician's order for an indwelling catheter. However, the clinical record lacked documented evidence of catheter care being provided or ordered. Staff interviews revealed that catheter care tasks were not populated in the Treatment Administration Record (TAR) until after the care was provided, leading to undocumented catheter care. The facility's policies required daily documentation of catheter care and perineal care, but these were not followed for Resident #19, resulting in incomplete medical records.
Failure to Provide Timely Infection Control Training
Penalty
Summary
The facility failed to ensure timely infection control training for one of its employees, specifically the Minimum Data Set (MDS) Coordinator hired on 08/16/2021. The personnel record for this employee documented that the last infection control training was completed on 01/25/2023, and there was no documented evidence of training for 2024. On 04/15/2024, the Human Resources (HR) Generalist confirmed that infection control training is required upon hire and annually, and acknowledged that the employee had not completed the training timely. The facility's policy, reviewed on 04/13/2023, mandates yearly infection control educational programs for all permanent nursing department employees.
Failure to Develop and Implement Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans for three residents with specific medical needs. Resident #19, who had an indwelling catheter, did not have a care plan addressing catheter care, despite a physician's order and the MDS Coordinator's acknowledgment that such a care plan was necessary. Similarly, Resident #24, who was on end-of-life/comfort care, lacked a care plan for this critical aspect of their treatment, even though there were multiple physician's orders and progress notes indicating the need for comfort medications and end-of-life care discussions with the family. The MDS Coordinator admitted that the care plan was not updated to reflect these needs. Resident #3, who had a bariatric bed with an air mattress to prevent skin breakdown, also did not have a care plan addressing the use of the air mattress. This omission was despite a physician's order and the MDS Coordinator's explanation that the care plan should include interventions to ensure the resident's safety, such as monitoring for entrapment and assessing the resident's abilities. The facility's policies on mobility devices, comprehensive care plans, and standards of care all emphasize the need for individualized care plans, which were not followed in these cases.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure a Minimum Data Set 3.0 (MDS) assessment was transmitted timely for a discharged resident. Resident #22, who had diagnoses including metabolic encephalopathy and major depressive disorder, was admitted to the facility and later discharged. The clinical record for Resident #22 lacked a discharge MDS assessment, and the MDS Coordinator confirmed that the required final validation report was not submitted within the mandated timeframe. The report was due by 12/04/2023 but was over 120 days late as of 04/09/2024. Additionally, the facility did not have a policy related to MDS final validation reporting, despite having a policy that required MDS data to be transmitted within seven days of a discharge event.
Failure to Ensure Resident Dignity and Address Behavioral Issues
Penalty
Summary
The facility failed to ensure residents were treated with dignity when residents felt bothered, annoyed, or harassed by other residents' comments and behaviors. Resident #1, who was admitted with diagnoses including type two diabetes mellitus and acquired absence of the right leg above the knee, was involved in an incident where Resident #2, diagnosed with unspecified dementia and anxiety, made a derogatory comment about Resident #1's appearance. Resident #1 retaliated with an expletive-laden comment about another resident. Staff had previously attempted to redirect Resident #1's behavior of staring at female residents, which had made several residents uncomfortable, including Resident #2. Despite these efforts, the administration was not fully aware of the extent of the issue, and Resident #2 was not assessed for psychosocial harm related to the incident, although they were sent to an inpatient behavioral health facility due to their behaviors. Resident #3, admitted with diagnoses including personal history of traumatic brain injury and mood disorder, experienced ongoing issues with their roommate, Resident #4, who was diagnosed with vascular dementia. Resident #4's behaviors, such as turning off lights while Resident #3 was reading, leaving the bathroom door open while using it, and throwing clothes on Resident #3's side of the room, caused significant distress to Resident #3. Despite multiple complaints and documented incidents dating back to September, the facility did not substantiate the Facility Reported Incident (FRI) as there was no outcome of psychosocial harm for Resident #3. However, Resident #3 was eventually provided with a room change after continued complaints and visible distress. The facility's policy on residents' rights, which includes the right to be treated with consideration, respect, dignity, and individuality, was not upheld in these cases. The administration and staff were aware of the ongoing issues but failed to take adequate measures to address the residents' concerns and ensure their dignity and comfort. The lack of timely and effective intervention led to continued distress for the affected residents, highlighting a deficiency in the facility's handling of resident interactions and behavioral issues.
Failure to Protect Non-Verbal Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure a non-verbal resident was not verbally abused by a staff member. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including traumatic brain injury and quadriplegia. On the morning of 12/28/23, a Dietary Aide (DA) overheard a Certified Nursing Assistant (CNA1) telling the resident to 'shut the (expletive) up' while the resident was receiving a beverage. The DA reported the incident to the Dietary Manager on 01/03/24, leading to an investigation. However, the resident's clinical record lacked documentation of the incident, and the resident's severe cognitive impairment made it difficult to ascertain their understanding of the event. The investigation included interviews with the resident, CNA1, the DA, and two other staff members. The Social Worker (SW) and Chief Nursing Officer (CNO) both noted the resident's severe cognitive impairment and inability to communicate effectively. Despite the DA's report and confirmation of the incident, the facility's Abuse Team and Administrator deemed the allegation unsubstantiated due to the lack of corroboration from other staff and CNA1's denial. CNA1 was suspended during the investigation and subsequently terminated on 01/03/24. The facility's policies on abuse prevention and resident rights emphasize the importance of protecting residents from all forms of abuse, including verbal and mental abuse. Despite these policies, the facility failed to document the incident properly and relied heavily on the judgment of staff members who did not witness the event. The Dietary Manager and Risk Management Director both acknowledged the inappropriateness of CNA1's behavior, but the facility ultimately did not substantiate the abuse allegation based on the available evidence and interviews.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure a Facility Reported Incident (FRI) was completed and submitted timely to the State Agency (SA) for allegations of abuse. Specifically, FRI #NV00069839, which involved an allegation of resident-to-resident abuse, was submitted to the SA on 11/14/23, despite the allegation being made on 11/12/23. The Chief Nursing Officer confirmed that the FRI was submitted late and outside of the required timeframes. The facility's policy on Abuse Prevention and Prohibition, last revised on 08/25/23, mandates that all alleged violations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property be reported immediately, but not later than two hours if the alleged violation involves abuse or results in serious bodily injury, and within 24 hours for all other allegations. The Administrator also verbalized these reporting requirements during the interview on 02/28/24.
Failure to Investigate and Document Alleged Abuse and Timely Report Investigation Results
Penalty
Summary
The facility failed to ensure an allegation of employee to resident verbal abuse was thoroughly investigated and documented for a resident. The incident involved a Certified Nursing Assistant (CNA) allegedly using abusive language towards the resident, which was overheard by a Dietary Aide (DA). The investigation was initiated seven days after the incident, and the resident's clinical record lacked documentation of the incident or investigation. Additionally, the resident's care plan was not updated to include methods and interventions to prevent further abuse or monitor for signs and symptoms of abuse or psychosocial effects. Interviews with the Administrator, Chief Nursing Officer (CNO), and Risk Management Director (RMD) revealed that the investigation was deemed unsubstantiated based on staff interviews and the resident's inability to communicate effectively. However, there was no documentation to support the investigation, including statements from the CNA or DA witness, and the resident's interview was not properly documented in the clinical record. The facility also failed to report investigation results within the required five working days for two Facility Reported Incidents (FRIs). One FRI involved an injury of unknown source for a resident, and the final report was submitted one day late. Another FRI involved resident-to-resident abuse, and the final report was submitted outside the required timeframes. The Administrator and CNO confirmed the late submissions and acknowledged that the final reports were not submitted within the required five-day timeframe as per the facility's policy on Abuse Prevention and Prohibition.
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