Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountain View Health & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that thawed waffles were stored in a Ziploc bag at room temperature on a bread rack instead of under proper cold holding conditions. The Dietary Manager stated the waffles did not need refrigeration and could be left out for use the next day, comparing them to bread. However, the Administrator and Assistant Manager later indicated that thawed, perishable food items should be refrigerated and that items left out should be discarded, and the facility’s dietary policy specifies that perishable foods must be kept at proper temperatures to prevent spoilage.
Failure to Perform Hand Hygiene During Meal Service: A dietary staff member discarded used sanitizing towelettes and then continued serving pozole after her hand was contaminated by food overflow on the steam table. The staff member did not perform hand hygiene after either contamination event, and the food continued to be served to residents. Interviews with the Dietary Aide, Dietary Supervisor, Dietary Director, and Administrator confirmed that hand hygiene was required when hands were exposed to food and after contamination.
A resident with a PEG tube had an external feeding syringe left partially exposed on the nightstand and later found unsealed in a dresser, while another resident with a peripheral IV had a saline flush syringe left unattended and out of its package on the nightstand. Interviews with a CNA, RN, DON, and Administrator confirmed the syringes were not stored or discarded as required and that the items were associated with infection control concerns.
Call Lights Not Kept Within Resident Reach: Three residents had call lights out of reach during observation. One resident with cerebral palsy, quadriplegia, and dependence for ADLs had the touch pad left on the bed while she sat in her wheelchair. Another resident with generalized muscle weakness and fall risk had the call light hanging on a sharps container above the bed. A third resident with dementia, muscle wasting, and severe cognitive impairment had the call light on the floor under the bed. RN H, the DON, and the Administrator stated call lights should be within reach, and the Administrator stated there was no call light policy.
Inaccurate MDS Coding for Resolved Pressure Ulcer: A resident’s MDS was coded as having an active sacral pressure ulcer even though the wound had already resolved and the weekly skin assessment showed no current ulcers. The resident, who had DM II and a history of a sacral Stage 3 pressure ulcer, stated the wound had healed months earlier and denied having any wounds. The MDS nurse acknowledged the coding error and stated MDS nursing was responsible for keeping resident information accurate.
Failure to timely complete the PASRR specialized services request for a resident with advanced Parkinson disease, severe functional dependence, and PASRR-positive findings. The care plan and PCSP identified PT, OT, ST, and habilitation-related services, but the NFSS request was not submitted within the required timeline and was denied without a follow-up submittal. Interviews showed inconsistent understanding among MDS, rehab, DON, and admin staff regarding PASRR status, service needs, and NFSS deadlines.
Care Plan Listed Resolved Pressure Ulcer as Active: A resident with DM and moderate cognitive impairment had a care plan that still listed a Stage 3 sacral pressure ulcer as active even though skin assessments showed no current ulcers and the resident said the wound had resolved months earlier. The MDS nurse acknowledged the wound had been resolved and said the active diagnosis was an error, while the DON stated the care plan was monitored quarterly by MDS nursing.
Failure to Provide Needed Nail Care: A resident with CVA and a chronic vegetative state was observed with long fingernails digging into the palm of a contracted hand. Staff interviews showed nail care was expected during routine ADL care, with CNAs, nurses, and leadership responsible for monitoring and trimming nails as needed, but the resident was not on the facility’s recent podiatry lists.
Failure to provide timely toenail care for a resident with DM, PVD, Parkinson’s disease, legal blindness, and right-sided hemiplegia/hemiparesis. The resident requested nail trimming and was observed with long, thickened toenails with a yellow hue, yet she was not on the podiatry service list and staff interviews showed the resident’s nail care was expected to be monitored by CNAs and nursing staff, with referral to podiatry for residents with diabetes or vascular concerns.
A resident with a BIMS of 14, a manual wheelchair, and diagnoses including unsteadiness on feet had a mini-fridge resting on a wobbly table with cardboard under one leg. Staff and leadership acknowledged the setup was a hazard and stated cardboard was not an approved fix, but the condition remained in place during repeated observations.
Medication bottles on the 500 Hall nurse cart were observed with dried drippings and colored spots on the sides of the bottles and on the medication drawer and lids. An LVN stated bottles should be cleaned after each use, and the DON and Administrator confirmed that nurses were responsible for keeping medication bottles clean to prevent cross contamination. Facility policy also stated that soiled medications and containers are to be removed from stock and that medication storage areas are to be kept clean.
Failure to provide ordered adaptive drinkware: A resident with chronic schizophrenia, polyneuropathy, and moderate cognitive impairment was supposed to use a sippy cup with meals, but was observed drinking coffee from an open cup during lunch on multiple occasions. On one occasion, he spilled coffee on his hand and the table. Staff stated the cup was intended to prevent spills and reduce the chance of injury from hot liquids, and that dining staff were responsible for ensuring residents had the correct drinkware.
The facility failed to develop and implement comprehensive, person-centered care plans addressing smoking for multiple residents who used tobacco. Several residents with documented nicotine dependence, significant mobility limitations, cardiopulmonary disease, cognitive impairment, seizure disorder, neuropathy, and visual impairment were smoking without individualized smoking risk assessments or care plan interventions for supervision, assistance to the designated smoking area, or lighter and cigarette control. One resident with lower-extremity amputations and impaired mobility smoked in the designated area without documented smoking supervision or hazard mitigation, while another with CHF, COPD, and schizophrenia reported smoking with staff-provided cigarettes and lighting but no known safety assessment. A cognitively intact resident’s care plan was only updated on the survey date to include smoking status and supervision needs, and another resident with seizures and moderate cognitive impairment was observed smoking after starting two weeks earlier, despite no smoking status or assessment documented in her record. Additional residents were found with cigarettes and, in one case, a lighter in their rooms, and staff, including a CNA and the Activities Director, reported concerns that smoking assessments were not consistently completed and that facility policies for smoking safety and control of smoking materials were not being followed.
The facility failed to consistently assess and manage residents’ smoking behaviors and to promptly report a fall, resulting in noncompliance with professional standards and care plans. Several residents with nicotine dependence, chronic smoking histories, cognitive impairment, mobility limitations, and serious cardiorespiratory conditions smoked without documented safe smoking assessments, clear supervision requirements, or individualized fire-safety interventions in their care plans. Some residents possessed cigarettes and lighters in their rooms despite facility policy requiring smoking materials to be secured and supervised, and staff responsible for overseeing smoking did not know which residents had completed smoking assessments. In a separate incident, a resident with a recent hip fracture, severe cognitive impairment, legal blindness, and a history of repeated falls fell during a transfer, and the CNA who witnessed the fall assisted the resident back to bed but did not immediately notify a nurse or the DON, contrary to facility fall and event-reporting policies.
Multiple residents who smoked or began smoking were not consistently assessed or care planned for safe smoking, and smoking materials were not always controlled according to facility policy. One resident with significant mobility and cognitive communication deficits and another with COPD and respiratory failure smoked in the designated area without documented safe smoking assessments or individualized supervision and safety interventions. A resident with bilateral BKAs, muscle weakness, and on anticoagulants was care planned not to keep smoking materials in the room, yet was found with a pack of cigarettes in his jacket. A cognitively impaired resident with seizure disorder, neuropathy, and impaired vision began smoking after admission, obtained cigarettes from other residents, and had no smoking status documented, no smoking assessment, and no smoking-related care plan interventions. Another resident with dementia and on anticoagulants was found with cigarettes and a lighter in his nightstand despite documentation that smoking materials were to be kept at the nurses’ station and a safe smoking assessment only being completed by the surveyor. Staff interviews confirmed they did not always know who had completed smoking assessments and that facility smoking policies and assessment requirements were not consistently followed.
A resident with multiple chronic conditions and moderately impaired cognition, but documented independent decision-making ability, requested a soda late at night. A CNA refused the request, stating it was too late and offering water instead, despite no care plan restrictions on soda or other beverages. The resident reported feeling angry and that his preferences were not respected, and a family member’s room video confirmed the CNA’s refusal. Another CNA present believed the refusal was wrong, and both the DON and Administrator acknowledged that residents have the right to choose food and beverages unless medically contraindicated, consistent with the facility’s resident rights policy on self-determination.
A resident with severe cognitive and physical impairments, requiring total care and two-person assistance for repositioning, was injured when a CNA attempted to reposition the resident alone, contrary to the documented care plan. The resident fell from the bed, sustaining a brain bleed, facial laceration, and fractures. Staff interviews and records confirmed the care plan was not followed, leading directly to the resident's injuries.
A resident who was totally dependent on staff for all care and required two-person assistance for repositioning was injured when a CNA attempted to reposition him alone, contrary to the care plan. The resident fell from the bed, sustaining a brain bleed, laceration, and facial fractures. Staff interviews confirmed the CNA was aware of the care plan requirements but did not request help or follow protocols, leading to the incident.
A resident with a chronic pressure ulcer was found without a required dressing on the wound, despite care plan orders and staff training to report missing dressings. Both a CNA and an LVN observed the absence of the dressing but did not notify nursing staff, and the DON confirmed this was not acceptable practice. Facility policy required routine skin assessment and prompt reporting of abnormalities.
Staff failed to follow Enhanced Barrier Precautions during wound care for a resident with a chronic pressure ulcer, as both an LVN and a CNA did not perform hand hygiene or use required PPE such as gowns and gloves before providing care, despite EBP signage and prior training. The resident, who was severely cognitively impaired and had multiple wounds, did not have a wound dressing in place, and this was not reported as required. The facility's infection control protocols were not followed during the observed care.
A resident with complex medical conditions and a preliminary positive AFB result was not placed in appropriate isolation upon return from the hospital. Facility staff did not consistently use PPE or follow airborne precautions, and the resident participated in group activities. Despite recommendations from the health department, the facility did not implement post-exposure interventions or monitor potentially exposed individuals, resulting in a failure to follow infection control policies.
A resident with a history of substance abuse and traumatic brain injury was admitted and subsequently readmitted without receiving the required admission packet or notice of resident rights. Staff interviews confirmed that neither the resident nor the family member received this information due to behavioral incidents and lack of communication among staff responsible for admissions. Facility policy requires provision and acknowledgment of these documents, but this process was not followed, and the necessary documentation was missing from the resident's record.
A resident with a history of traumatic brain injury and behavioral health issues was admitted and re-admitted without the required admission packet or signed agreement. Due to behavioral incidents and lack of clear communication, neither the resident nor the family received information on resident rights or facility policies, as confirmed by staff interviews and record review.
A resident with a history of substance abuse and cognitive impairment was discharged without receiving the required 30-day written notice, and the responsible party was only verbally informed. The Office of the State LTC Ombudsman was not notified of the discharge at the time it occurred, contrary to regulatory requirements. Facility staff confirmed that the standard notification procedures were not followed in this instance.
A resident with an indwelling catheter was found with their catheter bag lying on the floor rather than being hooked to the bed, as required by facility policy and care plans. Staff interviews confirmed that catheter bags should not touch the floor due to infection control concerns, and all staff acknowledged responsibility for ensuring proper placement. The resident's habit of unhooking the bag when repositioning contributed to the issue, but the deficiency was observed during a survey.
A resident with a history of substance abuse and traumatic brain injury exhibited acute behavioral symptoms, including aggression and suicidal ideation. Despite escalating behaviors, staff did not utilize the on-call psychiatric service for evaluation or intervention, relying instead on redirection and 1:1 supervision. The facility's behavioral management policy and care plan were not followed, and multiple staff confirmed that psychiatric support was not sought.
A resident with advanced dementia and hemiplegia, requiring a mechanical lift and two-person assistance for transfers, was injured when a hospice aide attempted to transfer him without the required equipment or help, leading to a fall and cervical fracture. The hospice and facility staff did not coordinate care plans or consistently communicate transfer requirements, and the hospice aide proceeded with the transfer alone after being unable to locate the lift sling. The facility did not have a fall prevention policy in place, and hospice staff were not routinely included in care plan meetings.
A hospice aide failed to use a mechanical lift and two-person assist when transferring a resident with severe cognitive and mobility impairments, resulting in a fall that caused a head laceration and cervical fracture. The resident's care plan and physician orders required total assistance with transfers, but the aide did not follow these protocols, and there was a lack of coordination between hospice and facility care plans. The incident highlighted gaps in communication and adherence to transfer procedures.
A resident with advanced dementia and hemiplegia, requiring total assistance and a mechanical lift for transfers, was transferred by a hospice CNA without the required equipment or assistance, resulting in a fall and serious injury. The hospice care plan did not reflect the need for a mechanical lift, and hospice staff were not consistently included in care planning or provided with updated facility care plans, leading to a lack of coordination and communication between facility and hospice staff.
A resident with advanced dementia and hemiplegia, requiring total assistance and a mechanical lift for transfers, was transferred by a hospice aide without the required equipment or two-person assistance, resulting in a fall and serious injury. The facility did not investigate the incident or coordinate care plans with hospice staff, failing to follow its own abuse/neglect prevention policies.
A resident with advanced dementia and significant mobility limitations was transferred by a hospice aide without the required mechanical lift and two-person assistance, resulting in a fall that caused a head laceration and cervical fracture. The facility did not initiate a timely or thorough investigation into the incident, and there was poor coordination between facility and hospice staff regarding the resident's care plan and transfer needs.
A resident with a history of cardiac and syncopal episodes alleged that a night nurse matching the description of an LVN struck him on the chest. Despite facility policy requiring immediate suspension of any staff member identified as an alleged perpetrator of abuse, the LVN was not promptly suspended after being identified. Staff interviews and record reviews revealed inconsistencies and lack of documentation regarding the suspension, and the LVN continued to work during the investigation, contrary to policy.
A resident with impaired cognition and visual impairment reported missing money from his wallet. Although staff were informed and an internal investigation began, the DON and ADON did not immediately notify the administrator or report the incident to the state agency as required by policy and law, resulting in a deficiency for failure to timely report suspected misappropriation of property.
The facility failed to ensure call lights were within reach for two residents, both with cognitive impairments, leading to a deficiency in accommodating their needs. One resident was found without a call light connected, while another had the call light on the floor, out of reach. This placed them at risk of unmet needs due to their inability to contact staff.
The facility failed to provide a private area for residents to make phone calls, compromising their privacy rights. A resident with diabetes and schizoaffective disorder was observed making a call in a public hallway, while another resident with Parkinson's and bipolar disorder used the phone at the nurses' station. Both expressed a need for more privacy. Staff interviews confirmed the absence of a designated private area, and attempts to provide one were unsuccessful, violating the facility's policy on resident rights.
A deficiency was identified involving a breach of privacy and confidentiality for residents' personal and medical records. The report highlights that residents have the right to access telephones, including TTY and TDD services, and a private space for calls. Two residents were mentioned in relation to privacy concerns, indicating a failure to ensure their communications and personal information remained confidential.
A dietary aide at an LTC facility used a pitcher placed on an unsanitized cart to serve tea, risking cross-contamination. Despite training on food safety, the aide's actions violated sanitation policies, potentially leading to foodborne illnesses. The unsanitized cart had visible dirt, and the facility's administration acknowledged the risk of bacterial infections from such practices.
Two incidents of infection control lapses were identified in a facility. A CNA failed to change gloves during incontinent care for a resident with dementia, while an LVN and ADON neglected to use required PPE during PEG tube medication administration for a resident on EBP. Both incidents were attributed to nervousness and oversight, despite existing training and signage.
A facility failed to change a resident's PICC line dressing as ordered, posing a risk of infection. The resident, with a history of sepsis and other conditions, had a PICC line requiring dressing changes every seven days. Despite being due for a change, the dressing remained unchanged, causing discomfort to the resident. Staff interviews confirmed the oversight and acknowledged the potential risk of infection.
A resident with moderately impaired cognition was found with unauthorized over-the-counter medications at their bedside, without an assessment for self-administration. The facility failed to provide adequate pharmaceutical services, as there were no orders for these medications, and the issue was not reported to management in a timely manner. Staff interviews revealed lapses in monitoring and adherence to the facility's policy on medication safety.
The facility failed to secure a treatment cart, leaving it unlocked and unsupervised with needles, dressings, and medicated ointments accessible. LVN A admitted to forgetting to lock the cart while attending to a resident with a doctor. The DON and Administrator confirmed the expectation for carts to be locked when unattended, as per facility policy.
A resident with a PICC line had their dressing change inaccurately documented by an RN, who signed off on the task without completing it. The resident's care plan required regular dressing changes, but an observation revealed the dressing was not updated as documented. Interviews with facility staff confirmed the error and highlighted the importance of accurate documentation to prevent inadequate care.
A resident with mobility issues had conflicting transfer instructions in their care plan, leading to inconsistent care and a fall incident. The care plan specified both a two-person Hoyer lift and a one-person transfer, causing confusion among staff. Interviews revealed that staff were unaware of the correct procedure, posing a risk of injury.
A resident in a long-term care facility, requiring a two-person transfer with a mechanical lift, was improperly transferred by a single CNA using a gait belt, leading to a fall and subsequent pain. The incident was not reported to nursing staff, and the resident's care plan contained conflicting instructions. Interviews revealed a lack of communication and adherence to the care plan, contributing to the deficiency.
A facility failed to ensure residents were free from physical restraints, as a resident with severe cognitive impairment was found with full bed rails without proper consent, physician's order, or care plan. The bed, provided by Hospice, was used for about a month without necessary documentation or authorization.
The facility failed to maintain an infection prevention and control program for a resident isolated for Covid-19. Despite training and clear signage, staff did not keep the resident's door closed, increasing the risk of cross-contamination and infection. The resident had severe cognitive impairment and multiple health conditions, and the facility's policy required doors to be closed for Covid-19 isolated rooms.
The facility failed to ensure proper catheter care for two residents, leading to risks of infection and catheter trauma. One resident was observed without a catheter leg strap, and another had a drainage bag lying on the floor and no catheter strap, contrary to their care plans and physician orders.
Improper Cold Holding and Storage of Thawed Waffles
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service practices related to maintaining and serving food in a palatable and safe manner. During a kitchen observation focused on food temperatures, a Ziploc bag containing defrosted waffles, dated the same day, was found sitting at room temperature on a bread rack. When questioned, the Dietary Manager stated that the waffles did not need refrigeration after thawing, explaining they were left out for use the following day and comparing them to bread, which is why they were stored on the bread rack. In subsequent interviews, the Administrator stated that thawed food items should be maintained at appropriate temperatures and that perishable food should be stored correctly in the refrigerator, indicating that the waffles should have been refrigerated after use. The Assistant Manager stated that thawed food items left out should be discarded due to the risk of bacterial growth and food spoilage. Review of the facility’s Dietary Services Policy & Procedure Manual (dated 2012) showed that perishable foods can spoil if not stored at proper temperatures, and spoiled food should not be served. The observed handling and storage of the thawed waffles did not align with these stated expectations and written policies.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to distribute and serve food in accordance with professional standards for food service safety in the kitchen. During an observation on 03/24/2026 at 11:58 AM, dietary staff member [NAME] F collected used sanitizing towelettes and wrappers and discarded them in the trash without performing hand hygiene before returning to work. Later during the same observation, [NAME] F was filling bowls of pozole at the steam table. At 12:10 PM, the bowl overflowed and wet her left hand, with dripping falling back into the steam table pozole insert, and she continued working without washing her hands. At 12:13 PM, the same thing occurred again when another bowl of pozole overflowed and wet her left hand, with dripping falling back into the steam table insert, and she again continued working without hand hygiene. No hand hygiene was observed for the next 10 minutes before the surveyor exited the kitchen, and pozole continued to be served to residents after the observed cross-contamination. During interviews, Dietary Aide D, [NAME] E, the Dietary Supervisor, the Dietary Director, and the Administrator all described hand hygiene expectations during kitchen work and meal service, including washing hands after contamination and when exposed to food. The Dietary Supervisor stated that if dripping landed back in the food, staff should stop immediately, wash hands, and obtain a replacement dish. Record review of the facility policy titled, Fundamentals of Infection Control Precautions, stated that hand hygiene is required when coming on duty, when hands are visibly soiled, and before and after handling food.
Unattended Syringes Left Exposed in Resident Rooms
Penalty
Summary
The facility failed to maintain its infection prevention and control program for two residents who were reviewed for transmission-based precautions. One resident had a PEG tube and enhanced barrier precautions in place, with a care plan focused on tube feeding and monitoring for complications. During observation, the resident’s external feeding syringe was found partially exposed on the nightstand, and on a later observation it was found unsealed inside the dresser among other contents. The resident stated staff used the tube for feeding and hydration and described the syringe used between feedings. A second resident had a diagnosis of sepsis and was coded as having a peripheral IV access site on admission. The resident’s care plan included enhanced barrier precautions and interventions to flush IV ports/lines as ordered and monitor for signs and symptoms of infection. During observation, a saline flush syringe was found unattended and out of its package on the resident’s nightstand. The resident stated she had just returned from PT, had not noticed the syringe, did not know who had provided it or when, and did not know what it was used for. During interviews, a CNA stated an unattended syringe out of its package should be reported immediately and identified leaving syringes in resident rooms as an infection control issue. An RN stated saline flush syringes were disposable after removal from the package and that external feeding syringes could be reused up to 24 hours only if stored in a Ziplock bag when not in use. The Administrator and DON stated the feeding syringe should have been stored and sealed away and the saline flush syringe should have been discarded after use; both also stated that nurses, ADONs, and the DON were responsible for infection prevention practices.
Call Lights Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure resident call lights were within reach for 3 of 28 residents reviewed for call lights. During observation and record review, Resident #13, a cognitively intact female with cerebral palsy, quadriplegia, chronic lower extremity contractures, seizure disorder, and dependence for activities of daily living, was observed sitting in her wheelchair while her call light touch pad was on her bed about 6 feet away. She stated she was dependent on staff for everything she needed and could not move her wheelchair to obtain the call light. Resident #56, a cognitively intact male with generalized muscle weakness who required partial/moderate assistance, was observed asleep in bed with the call light hanging on a sharps container to the right of the bed above the head of the bed. His care plan identified him as a fall risk and included interventions to ensure the call light was within reach and to encourage him to use it for assistance as needed. Resident #87, a female with dementia, muscle wasting and atrophy, and muscle weakness, had a BIMS score of 0 indicating severe cognitive impairment. Her care plan included staff intervention to provide a safe environment and ensure the call light was within resident reach. On observation, her call light was on the floor under the bed and out of reach. RN H stated call lights were for residents to call staff for their needs and that nursing staff rounded every 2 hours to ensure call lights were within reach. The DON and Administrator stated all staff were responsible for ensuring call lights were within reach, and the Administrator stated there was no call light policy.
Inaccurate MDS Coding for Resolved Pressure Ulcer
Penalty
Summary
The facility failed to ensure Resident #63’s assessments accurately reflected her status when the MDS was coded as if she had an active pressure ulcer on the sacrum, even though the wound had resolved. Record review showed the resident was a [AGE]-year-old female admitted on 11/07/2025, with a history of Type II Diabetes Mellitus. Her care plan had identified a Stage 3 pressure ulcer to the sacrum, with interventions including ordered treatments and monitoring for effectiveness, but the weekly skin assessment documented that she did not have any pressure, venous, arterial, or diabetic ulcers at the time of assessment. During interview, the resident stated she had been admitted with a wound that had resolved months earlier and denied having any wounds at the time. The MDS nurse stated the sacral pressure ulcer had resolved since 11/30/2025 and acknowledged the MDS was not updated correctly, stating MDS nursing was responsible for monitoring and confirming that resident information was accurate. The DON stated floor nursing initiated the baseline MDS and MDS nursing completed the comprehensive MDS, but she did not believe there was a risk for residents having active wound care noted in the MDS.
Failure to Timely Complete PASRR Specialized Services Request
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR Level II determination and PASRR evaluation report into Resident #149’s assessment, care planning, and transitions of care. The resident was admitted on 07/08/2025 and later discharged on 02/25/2026. Record review showed the resident had advanced Parkinson disease, volvulus of the sigmoid colon, large bowel obstruction, and was debilitated. The quarterly MDS indicated the resident was rarely or never understood and was dependent for multiple ADLs, including oral hygiene, bathing, dressing, rolling, and bed, toilet, and wheelchair transfers. The care plan dated 12/18/2025 included a PASRR focus with interventions stating specialized services would be provided per IDT recommendations, including PT, OT, ST three times weekly and habilitation coordination. The PCSP dated 12/18/2025 identified a new finding that the resident required PT and OT assessment and therapy services, and the PCSP dated 01/15/2026 still coded PT and OT as new while also identifying a new need for ST assessment and therapy services. The NFSS Therapist, Referring Physician, and NF Administrator Therapy Signature page showed the PT, OT, physician, and administrator signed on 1/15/2026. The complaint intake stated the NF was notified and instructed to submit a NFSS Request by a specific deadline but failed to do so, and the request was denied without a follow-up submittal to ensure approval for specialized services. Interviews showed the Director of Rehabilitation, DON, MDS nurse, PT, and Administrator each had varying understanding of the PASRR process and timelines. The MDS nurse stated she was responsible for meeting NFSS timelines and acknowledged the timeline for Resident #149’s specialized services identification and therapist signatures was not within the 20-day NFSS requirement. The PT stated the NFSS form was not signed until 1/15/2026 and that she was not familiar with the PASRR process. The Administrator stated he was not aware of the resident’s PASRR status or specialized services needs, and the DON stated she was not aware of any delay in services.
Care Plan Listed Resolved Pressure Ulcer as Active
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for Resident #63. Record review showed the resident was admitted on 11/07/2025, had a history of Type II Diabetes Mellitus, and had a Quarterly MDS with a BIMS score of 11, indicating moderate cognitive impairment. The resident’s care plan, revised 11/12/2025 and marked resolved on 03/26/2026, still listed a pressure ulcer or potential for pressure ulcer development: Stage 3 to the sacrum, with interventions including administering treatments as ordered and monitoring for effectiveness. A weekly skin assessment documented that Resident #63 did not have any pressure, venous, arterial, or diabetic ulcers at the time of assessment, and the resident stated the wound had resolved months earlier and that she had no wounds at the time. The MDS nurse stated the sacral pressure ulcer had been resolved since 11/30/2025 and acknowledged the active wound diagnosis in the care plan was an error. The DON stated floor nurses composed the baseline care plan and MDS nursing monitored the comprehensive care plan every 3 months, and she did not think there was a potential risk in having a resolved diagnosis listed as active.
Failure to Provide Needed Nail Care
Penalty
Summary
The facility failed to ensure Resident #40 received necessary ADL assistance to maintain grooming and personal hygiene when her fingernails were not trimmed. Resident #40 was a female with a history of CVA and chronic vegetative state. Her quarterly MDS indicated no BIMs score, and Section GG showed personal hygiene tasks were not attempted due to medical condition or safety concerns. Her care plan, revised on 03/18/2026, identified an ADL self-care deficit and directed total assistance with personal hygiene care. On 03/24/2026 at 10:13 a.m., Resident #40 was observed with contracted fingers on the right hand, with fingernails digging into the palm and the fingernails appearing long. She was awake but not alert or oriented and was unable to answer questions. During interviews, CNA B stated that staff were responsible for reviewing nails during daily care and ADLs and that long nails could lead to infection, fungus development, and ingrown nails. CNA I stated fingernails were trimmed on Sundays and as needed, and that CNAs and nurses were responsible for ensuring nails were trimmed. RN H stated fingernails were trimmed as needed when observed to be long or when requested by the resident, and that nurses were responsible for cutting fingernails and ensuring they were trimmed. The Administrator stated fingernails were trimmed by CNAs and nurses and that nurses, DON, and ADONs were responsible for ensuring residents' fingernails were trimmed. The DON stated staff monitored and tracked the condition of residents' toes and fingernails daily during rounds and assessments, and that fingernails were trimmed during shower days. Facility podiatry lists dated 12/09/2025, 02/03/2026, and 03/06/2026 did not include Resident #40. The facility policy stated nail care should be performed regularly and safely, and that nails that are ingrown, thickened, or infected should be cared for by a podiatrist, with the nurse ensuring referral to podiatry.
Failure to Provide Timely Toenail Care
Penalty
Summary
The facility failed to ensure proper foot care for Resident #119, who had an active physician order for podiatry consultation for foot care. Resident #119 was a cognitively intact female with diagnoses including peripheral vascular disease, Parkinson’s disease, legal blindness, and type 2 diabetes mellitus with hyperglycemia. Her care plan indicated she needed assistance with ADLs and mobility due to right-sided hemiplegia/hemiparesis and age-related physical debility, with extensive assistance needed for personal hygiene. During an observation and interview, Resident #119 stated she did not like the length of her toenails and wanted someone to cut them. She said she had already asked direct care staff but could not recall when or who she asked. Observation of her exposed right foot showed long and thickened toenails with a yellow hue under the nail. The resident was not listed on the facility’s podiatry service lists for the prior three months. Interviews with CNA, RN, the Administrator, and the DON showed that staff expected toenails to be reviewed during care and that nursing staff were responsible for nail assessment and follow-up. Staff stated residents with diabetes, vascular disease, fungus, or other concerns should be referred to podiatry, and the DON stated podiatry visited routinely and as needed. The facility policy stated nail care should be performed regularly and safely, and that ingrown, thickened, or infected nails should be cared for by a podiatrist with referral by the nurse. Despite these expectations and the resident’s request, her toenails were not trimmed and she was not identified on the podiatry service list.
Unstable Furniture Supporting Mini-Fridge
Penalty
Summary
The facility failed to ensure Resident #123’s environment remained free from accident hazards when a mini-fridge was observed resting on top of a wobbly table with a folded cardboard placed under the front left leg. The resident was cognitively intact with a BIMS score of 14, used a manual wheelchair for mobility, and had diagnoses including muscle wasting and atrophy in multiple sites, unsteadiness on feet, and other abnormalities of gait and mobility. Her care plan included 1-person assistance for all ADLs and noted interventions related to fall risk and keeping furniture in a locked position. Resident #123’s room was observed on multiple occasions with the mini-fridge still on the unstable table. During the initial observation, the resident stated the table belonged to her and that staff had fixed it by placing the folded cardboard under the leg, though she could not recall when or which staff member did this. She also stated she had not notified the facility about the table’s condition. The maintenance supervisor later stated that placing cardboard under a wobbly table was not an approved solution and said the cardboard had been added later by an unknown staff member. Interviews with CNA, RN, the maintenance supervisor, the Administrator, and the DON confirmed that the unstable table with the mini-fridge on top was considered a hazard. Staff described environmental hazards as items such as clutter, cords, furniture in passageways, or unstable furniture, and stated that compromised furniture should be reported immediately. The maintenance supervisor stated he had reviewed the resident’s furniture when it was brought in and had not declined any furniture for safety concerns, but no in-service for identifying environmental hazards was recalled by the maintenance supervisor or Administrator. The policy provided to surveyors addressed biological hazards, bodily fluids, and soiled linens, and did not address compromised furniture.
Medication Bottles Found Soiled on 500 Hall Cart
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with currently accepted professional principles for 1 of 4 medication carts reviewed, specifically the 500 Hall nurse cart. During an observation of the medication cart, a bottle of lactulose and a bottle of milk of magnesia were found with dried drippings on the sides of the bottles. Colored spots were also observed on the side of the medication drawer and on the lids of one bottle of MiraLAX and three bottles of lactulose. During interview, the LVN stated that medication bottles were to be cleaned after each use and could be wiped down with wipes available in the cart. The LVN stated it was the nurse's responsibility to ensure the bottles were clean after each use. The DON and Administrator both stated that medication bottles were to be cleaned after every use to prevent cross contamination, and the Administrator stated that the nurse pouring the medication was responsible for ensuring the bottles were cleaned. Facility policy titled Medication Storage in the Facility stated that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, and that medication storage areas are kept clean, well-lit, and free of clutter.
Failure to Provide Ordered Adaptive Drinkware
Penalty
Summary
The facility failed to provide Resident #12 with the physician-ordered sippy cup for drinking fluids during lunch meals on 03/24/2026, 03/25/2026, and 03/26/2026. Resident #12 was a [AGE]-year-old male with an original admission date of 06/03/2021 and a readmission date of 12/08/2025. His history and physical listed chronic schizophrenia and polyneuropathy, and a psychiatric subsequent assessment documented drug induced subacute dyskinesia. His quarterly MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and Section GG indicated he needed supervision or touching assistance while eating. Resident #12’s care plan, revised on 11/14/2025, included a regular diet and the use of a sippy cup with meals, and the physician order dated 12/08/2025 remained active. Despite this, observations during lunch showed him drinking coffee from a cup without a lid on each of the three days reviewed. On 03/25/2026, he was observed spilling coffee on his left hand and on the table. Staff interviews stated that the sippy cup was intended to prevent spilling liquids and reduce the chance of injury from hot liquids, and that dining staff were responsible for ensuring residents had the correct drinkware. The facility did not provide a policy regarding adaptive aids before exit.
Failure to Develop and Implement Comprehensive Smoking Safety Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans addressing smoking for multiple residents who used tobacco. The facility’s own policy required development of a comprehensive care plan within seven days of the comprehensive assessment, with ongoing review and revision based on changing needs. Record review showed that several residents had documented nicotine dependence or reported smoking, yet their care plans did not include specific smoking-related problem statements, risk assessments, or interventions such as supervision, designated smoking locations, lighter control, or fire prevention strategies. Instead, care plans focused on other medical conditions and, in some cases, only included general education about the adverse effects of tobacco without individualized smoking safety measures. For one male resident with osteomyelitis, multiple amputations, peripheral vascular disease, CAD, DM2, impaired mobility, and chronic tobacco use, the admission MDS documented nicotine dependence and significant physical limitations, including a left below-knee amputation and toe amputations that impaired safe ambulation to and from the smoking area. His care plan addressed hypertension, diabetes, anticoagulant therapy, impaired cognition, ADL self-care deficit, and enhanced barrier precautions, and included tobacco education, but did not include smoking supervision interventions, assistance to the designated smoking area, lighter control, or individualized hazard mitigation. This resident reported that he smoked in the designated area, began smoking about a week after admission, did not know if the facility had evaluated him for smoking safety, and did not recall being educated on the facility’s smoking policies or the need to notify staff when he wished to start smoking. During observation, a CNA lit his cigarette, noted his hand tremors, and asked if he needed help, indicating concern about his ability to smoke safely. Another male resident had extensive cardiopulmonary and psychiatric diagnoses, including CHF, CKD, pleural effusion, nicotine dependence, atherosclerotic heart disease, respiratory failure with hypoxia, pneumonia, HTN, anemia, and schizophrenia. His quarterly MDS and care plan addressed CHF, COPD, oxygen therapy, monitoring for respiratory distress, lab monitoring, fall precautions, skin integrity, antidepressant monitoring, and pain, but did not include a smoking safety assessment or smoking-related interventions. He stated he smoked in the designated area, that staff provided and lit his cigarettes, and that he did not know if he had been assessed to smoke safely. A female resident with intact cognition (BIMS 15) had her care plan updated only on the survey date to reflect that she was a smoker and required constant supervision while smoking, with interventions for designated smoking area use, removal of smoking materials from her room, and monthly safe smoking assessments. She reported that staff kept her cigarettes and lighter and were responsible for lighting her cigarettes. A female resident with seizure disorder, DM2 with hyperglycemia, bipolar disorder, metabolic encephalopathy, anxiety, diabetic neuropathy, impaired vision, chronic pain, and other conditions had a history and physical that documented denial of tobacco use and no documentation identifying her as a smoker. Her MDS showed moderately impaired cognition (BIMS 12), supervision needs for eating, transfers, and toileting, and impaired vision requiring corrective lenses, but did not document smoking status or a smoking assessment. Her care plan addressed HTN, diabetes, diuretic therapy, impaired vision, depression, and ADL self-care deficit, and included education on adverse effects of tobacco, but lacked a specific smoking problem statement, risk assessment, or interventions for supervision or safe smoking location. She was later observed sitting in the smoking area with other residents who were smoking and stated she had started smoking about two weeks earlier, obtained cigarettes from other residents, and did not know if she had been evaluated for safe smoking or the facility’s smoking rules beyond needing to go outside. Additional observations showed other residents possessing cigarettes and, in one case, a lighter in their rooms. One resident admitted to being a smoker, showed a pack of cigarettes in his jacket pocket, and stated he was supposed to turn them in to the facility for safekeeping, was aware of the policy that residents should not keep such items, and denied having a lighter or matches. Another resident stated he did not know he needed to inform the facility that he smoked and did not believe he had been evaluated for safe smoking; he knew he could not smoke inside and had to use the designated area. This resident had a pack of cigarettes and a lighter in his nightstand and acknowledged he knew he needed to give smoking equipment to staff, explaining that the items had been given to him by a family member the previous day. Staff interviews confirmed that cigarettes and lighters were supposed to be kept in a locked box, that staff supervised residents during smoking times, and that some staff were concerned that residents with tremors and poor hand control might not have appropriate smoking assessments. The Activities Director acknowledged the facility was not following its policies and procedures for resident safety and that residents having lighters in their rooms could result in fire hazards, while the facility’s comprehensive care planning policy required person-centered care plans addressing identified needs from the assessment, including review and revision after each MDS assessment.
Failure to Implement Safe Smoking Practices and Timely Fall Reporting
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards, person-centered care plans, and resident choices, specifically related to smoking assessment/supervision and fall reporting. Multiple residents with documented or reported nicotine dependence or smoking behavior did not have complete or consistent smoking assessments, care plans, or supervision interventions in place as required by facility policy. For one resident with chronic tobacco use, osteomyelitis with toe amputation, peripheral vascular disease, impaired mobility, and cognitive deficits, the care plan included education on adverse effects of tobacco but did not clearly identify specific smoking supervision interventions, assistance to and from the designated smoking area, lighter control, fire prevention strategies, or individualized hazard mitigation despite his mobility and cognitive limitations. Another resident with a diagnosis of nicotine dependence, COPD, respiratory failure with hypoxia, and other serious cardiorespiratory conditions had a care plan that only encouraged refraining from smoking and did not include a specific smoking supervision plan, designated smoking area guidance, staff supervision requirements, smoking safety precautions, lighter control procedures, or fire risk mitigation interventions; there was no safe smoking assessment in the electronic record. A third resident with a history of chronic smoking, respiratory issues, substance use disorder, and anxiety had an admission MDS that did not clearly document smoking behaviors or supervision requirements, even though a separate safe smoking assessment indicated supervision was required. Her care plan, updated later, identified her as a smoker and required that she always be supervised by a visitor or staff member, that she smoke only in the designated area, that no oxygen be present while she smoked, that no smoking materials be stored in her room, and that monthly safe smoking assessments be completed. Another resident with seizure disorder, diabetic neuropathy, impaired vision, and chronic pain denied tobacco use in the history and physical, and there was no documentation identifying her as a smoker, no smoking status on the MDS, and no smoking assessment completed. Her care plan included education on adverse effects of tobacco but did not identify her as a smoker or include interventions for supervision, safe smoking location, or monitoring for smoking-related hazards. This resident was later observed sitting in the smoking area near other residents who were smoking and reported she had started smoking about two weeks earlier using cigarettes given by other residents; she stated she did not know if she had been evaluated to safely smoke and did not know the facility’s smoking rules beyond needing to go to the designated smoking area. Another resident with dementia, atrial fibrillation, anticoagulant therapy, and other chronic conditions had a care plan that encouraged avoidance of smoking for GERD management and stated smoking materials were kept at the nurses’ station, but it did not clearly describe supervision frequency, monitoring for burns, or risk mitigation related to his cognitive impairment and anticoagulant use. A safe smoking assessment completed by the surveyor at the time of entrance documented that he was safe to smoke unsupervised and that all smoking materials were kept at the nurses’ station, but during an interview he stated he did not know he needed to inform the facility that he smoked, did not know he had been evaluated to safely smoke, and had a pack of cigarettes and a lighter in his nightstand that had been given by a family member. Another resident admitted to being a smoker and had a pack of cigarettes in his jacket pocket, stating he had just received them from a family member and was supposed to turn them in to the facility for safekeeping; he reported he did not have a lighter and was aware of the policy that residents should not keep such items and must turn them in. Additional interviews with residents revealed that several smokers did not know whether they had been assessed for safe smoking, while staff interviews showed that CNAs supervising smoking did not know which residents had completed smoking assessments and expressed concern about residents with tremors and poor hand control smoking without clear confirmation of individualized safety evaluations. The deficiency also includes a failure to report and respond to a resident fall according to facility policy. One resident with a nondisplaced intertrochanteric fracture of the left femur, atrial fibrillation, legal blindness, repeated falls, mild dementia, and severe cognitive impairment (BIMS score of 01) required staff assistance for bed mobility, transfers, and ambulation and had a care plan identifying him as at risk for falls, with interventions including staff assistance with transfers. A CNA reported that this resident lost balance during a transfer from wheelchair to bed and fell onto his buttocks and left side onto a floormat. The CNA acknowledged she knew she was required to report the fall immediately to the charge nurse or DON but forgot to do so and assisted the resident back to bed without notifying licensed staff at that time. Another CNA confirmed he assisted the first CNA in helping the resident after the fall and stated that the first CNA told him she would notify the charge nurse. Interviews with other CNAs, an LVN, the DON, and the Administrator confirmed that facility expectations and policies required all falls to be reported immediately to a licensed nurse for assessment, that CNAs were not permitted to independently determine a resident’s condition after a fall or reposition the resident without nursing evaluation, and that this fall was not reported as required.
Failure to Conduct and Implement Safe Smoking Assessments and Controls
Penalty
Summary
The deficiency involves the facility’s failure to maintain a smoking environment free of accident hazards and to provide adequate supervision and assessment for multiple residents who smoked or wished to smoke. For one male resident with a history of daily tobacco use, multiple vascular diseases, diabetes, impaired mobility including a left below-knee amputation and toe amputations, and cognitive communication deficits, the facility documented nicotine dependence but did not complete a safe smoking assessment. His care plan addressed various medical conditions and included general education on adverse effects of tobacco, but it did not specify smoking supervision interventions, assistance to and from the designated smoking area, lighter control measures, fire prevention strategies, or individualized hazard mitigation despite his mobility and cognitive limitations. This resident reported he began smoking about a week after admission, requested staff to take him outside, and received cigarettes from staff in the designated smoking area, but he did not know if he had been evaluated for smoking or educated on the facility’s smoking policies. Another male resident with diagnoses including nicotine dependence, COPD, respiratory failure with hypoxia, pneumonia, CKD stage 5, anemia, and bipolar disorder had inconsistent documentation regarding smoking status: nicotine dependence was listed as a diagnosis, but the social history stated he denied tobacco use. His quarterly MDS showed intact cognition with mild recall difficulty. His care plan addressed coronary artery disease and included an intervention to encourage him to refrain from smoking, but it did not include a specific smoking supervision plan, designated smoking area guidance, safety precautions, lighter control procedures, or fire risk mitigation interventions, and there was no safe smoking assessment in the electronic record. This resident stated he was a smoker, smoked in the designated area, staff provided his cigarettes and lit them for him, and he did not know if he had been assessed to smoke safely. A third male resident with bilateral below-knee amputations, infections of the amputation stumps, muscle weakness, unsteadiness on feet, age-related cognitive decline, major depressive disorder, anxiety disorder, and on anticoagulant and diuretic therapy had a care plan identifying that he smoked. The plan stated he should smoke only in designated areas, have no oxygen present while smoking, be informed of the smoking policy, be prohibited from storing smoking materials or igniters in his room, and receive a monthly safe smoking assessment. He was considered safe to smoke unsupervised, and a safe smoking assessment documented that he knew the designated smoking area, could get there independently, and could safely light, extinguish, and dispose of smoking materials. However, during observation he was found in bed with a pack of cigarettes in his jacket pocket, which he said had just been given by family and that he was supposed to turn in to the facility for safekeeping, indicating that cigarettes were present in his room contrary to the care plan and policy. A female resident with seizure disorder, metabolic encephalopathy, bipolar disorder, anxiety disorder, diabetic neuropathy, impaired vision requiring corrective lenses, chronic pain, obesity, and other chronic conditions had documentation in the history and physical that she denied tobacco use, and there was no documentation identifying her as a smoker. Her MDS showed moderately impaired cognition and need for supervision with eating, transfers, and toileting, but did not identify her as a smoker and contained no smoking status or assessment. Her care plan addressed hypertension, diabetes, diuretic therapy, impaired visual function, depression, and ADL self-care deficit, and included education on adverse effects of tobacco, but there was no problem statement identifying her as a smoker, no smoking risk assessment, and no interventions for supervision or safe smoking location. Facility record review confirmed there were no safe smoking assessments for her. During observation in the smoking area, she sat near other residents who were smoking while a CNA supervised the group; she stated she had started smoking about two weeks earlier, obtained cigarettes from other residents, did not know if she had been evaluated to smoke safely, and only knew she had to go outside to smoke. Another male resident with dementia, hypertension, diabetes, atrial fibrillation, arthritis, GERD, and cognitive communication deficit had a social history documenting that he denied smoking at admission. His MDS showed moderate cognitive impairment and shortness of breath. His care plan addressed hypertension, diabetes, anticoagulant therapy, GERD, arthritis, and cognitive impairment, and included education encouraging avoidance of smoking for GERD management, and indicated that smoking materials were kept at the nurses’ station. However, prior to the survey the care plan did not clearly describe supervision frequency, monitoring for burns, or risk mitigation related to his dementia and anticoagulant therapy, and it was updated only on the date of the investigation. The safe smoking assessment on file, indicating he was safe to smoke unsupervised and that all smoking materials were kept at the nurses’ station, was completed by the investigator at the time of entrance, not by facility staff beforehand. During observation, this resident was found in bed with a pack of cigarettes in his nightstand and a lighter inside the pack; he stated he did not know he needed to inform the facility that he smoked, did not believe he had been evaluated to smoke safely, and said the cigarettes and lighter had been given by family the previous day. Staff interviews further demonstrated gaps in the facility’s smoking safety practices. A CNA who supervised smoking breaks stated that cigarettes and lighters were kept in a locked box, staff handed out cigarettes, and residents were supervised while smoking, but she did not know which residents had completed smoking assessments and expressed concern that some residents with tremors and poor hand control might not have appropriate assessments. The DON stated that residents who identified as smokers on admission were supposed to receive a smoking assessment and that residents should not smoke without an assessment, but acknowledged that staff often relied on routine and smoking schedules rather than verifying current assessments. The ADON, Administrator, and Activities Director each stated that residents should be assessed before smoking and that residents having lighters or smoking equipment in their rooms could create fire hazards or result in burns or injuries. Review of the facility’s Uniform Smoke Free Policy showed requirements for assessments, prohibition of smoking in resident rooms, storage of smoking paraphernalia in secured areas, and direct supervision for residents assessed as unsafe, which were not consistently implemented for the residents reviewed.
Failure to Honor Resident Beverage Choice and Self-Determination
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to make choices about aspects of his daily life, specifically his beverage preference. The resident was an adult male with multiple diagnoses including vascular dementia, type 2 diabetes mellitus, hypertension, chronic systolic congestive heart failure, COPD, seizure disorder, left-sided hemiparesis, hemiplegia, and peripheral vascular disease. His quarterly MDS showed a BIMS score of 10, with cognitive skills for daily decision-making documented as independent. Review of his care plan revealed no restrictions related to soda, caffeine, or other beverages. According to a psychological services progress note and subsequent interviews, the resident reported that on a late-night occasion he requested a soda from a female CNA, who refused and told him it was too late for a soda and offered water instead. The resident stated he felt angry, asserted that he could make his own decisions, and reported that the CNA ignored him and walked away. He reported that this interaction made him feel like the facility did not care about his preferences. A family member, who had video cameras installed in the resident’s room, stated they reviewed the footage after the resident reported the incident and confirmed hearing the CNA offer water instead of soda. In interviews, the CNA involved stated she knew the resident already had a soda and, based on her own judgment, thought it would be best to offer water, acknowledging that she should have provided the soda and consulted the charge nurse. Another CNA present at the time stated it was wrong not to ask a supervisor and that denying the soda could cause the resident to feel his choices were not being considered. The DON and Administrator both stated that residents have the right to make choices regarding food and beverage preferences unless medically contraindicated, that there were no indications in this resident’s care plan restricting soda at night, and that staff are responsible for respecting resident wishes. The facility’s Resident Rights policy states that residents have the right to self-determination, to make choices about aspects of their life in the facility, and to exercise their rights without interference, coercion, discrimination, or reprisal.
Failure to Follow Two-Person Repositioning Care Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to implement a comprehensive, person-centered care plan for a resident who was totally dependent on staff for all activities of daily living and required two-person assistance for repositioning. The resident, who was nonverbal, had a tracheostomy, and suffered from multiple complex medical conditions including anoxic brain injury, cirrhosis, and severe cognitive impairment, was care planned for two-person assistance during repositioning due to his total dependence and limited mobility. Despite this, a CNA attempted to reposition the resident alone, without the required assistance. During the solo repositioning attempt, the resident rolled off the bed and struck his head on a suctioning machine, resulting in a brain bleed, a 2 cm laceration above the right eyebrow, an orbital fracture, and a sinus fracture. The incident was documented in the resident's progress notes and confirmed by interviews with staff, including the CNA involved, who admitted to not following the care plan and acknowledged being aware of the two-person requirement. The CNA did not request help, even though other staff were nearby and available. Interviews with nursing staff and facility leadership confirmed that the care plan and Kardex clearly indicated the need for two-person assistance for repositioning, and that all staff had been trained to access and follow these care plans. The failure to follow the established care plan directly led to the resident's fall and subsequent injuries, as confirmed by multiple staff interviews and record reviews.
Failure to Provide Required Two-Person Assistance During Repositioning Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance during peri care and repositioning of a resident who was totally dependent on staff for all activities of daily living. The resident, who was nonverbal, in a vegetative state, and required two-person assistance for all repositioning and peri care as documented in his care plan and Kardex, was repositioned by a single CNA without the required help. During this process, the resident rolled off the bed and struck his head on a suctioning machine, resulting in a brain bleed, a 2 cm laceration above the right eyebrow, orbital fracture, and sinus fracture. The resident had a complex medical history, including long-standing alcohol use disorder, alcoholic encephalopathy, cirrhosis, pancreatitis, gastrointestinal bleeding, hypertension, and an anoxic brain injury requiring a tracheostomy and gastrostomy. He was admitted for skilled nursing care, medical management, and total assistance with activities of daily living. The care plan clearly indicated the need for two-person assistance for all repositioning and peri care due to his severely impaired cognition and physical limitations. Despite being aware of the care plan requirements and having received prior training, the CNA proceeded to reposition the resident alone, did not request assistance, and did not follow established protocols. Multiple staff interviews confirmed that the CNA knew the resident required two-person assistance and that the care plan and Kardex were accessible and should have been followed. The incident was attributed directly to the CNA's failure to adhere to the resident's care plan, resulting in significant injury to the resident.
Failure to Maintain Pressure Ulcer Dressing as Ordered
Penalty
Summary
A resident with a chronic right gluteal pressure ulcer did not receive necessary treatment and services consistent with professional standards of practice. The resident, who was severely cognitively impaired and required pressure ulcer care, was observed without a dressing on his pressure ulcer as ordered in his care plan. During an observation, staff found a thick white substance on the resident's buttocks and directly on the pressure injury, but no dressing was in place. The care plan required the administration of treatments as ordered and monitoring the effectiveness by replacing loose or missing dressings. Interviews revealed that both a CNA and an LVN noticed the absence of the wound dressing but did not report it, despite being trained to immediately notify nursing staff of missing dressings for residents with pressure ulcers. The DON confirmed that wounds without dressings increase infection risk and delay healing, and stated that it was the responsibility of the wound care nurse to ensure dressings were in place as ordered. The facility's policy required staff to assess skin routinely and report abnormalities to nursing staff to prevent skin breakdown and promote healing.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) during wound care for a resident with a chronic right gluteal pressure ulcer. On the observed date, an LVN and a CNA entered the resident's room, which had an EBP sign posted, but neither performed hand hygiene nor donned the required personal protective equipment (PPE) such as gowns and gloves before making physical contact with the resident. Both staff members proceeded to turn the resident and provide care without following these infection control protocols. The resident involved was an elderly male with a history of a chronic right gluteal pressure ulcer, iron deficiency, and anemia, and was severely cognitively impaired. His care plan required the use of pressure-reducing devices, regular wound care, and the application of nonsurgical dressings and medications. During the observed care, a second stage II ulcer was identified, and it was noted that the wound dressing was missing, which had not been reported to the licensed staff as required by facility protocol. Interviews with the involved staff revealed that both had been trained on EBP and the necessity of using PPE when caring for residents with wounds, but they could not provide a reason for not following these procedures during the incident. The DON confirmed that EBP signage was in place and that staff were expected to use gowns and gloves for direct contact with residents under these precautions. The facility's infection control policy required hand hygiene and the use of PPE to prevent the spread of infection, but these protocols were not followed during the observed care.
Failure to Implement Infection Control Precautions for Suspected TB Case
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the case of a resident who was admitted with multiple complex medical conditions, including cavitation pneumonia, end-stage renal disease, and diabetes mellitus. The resident had a history of hospitalizations for severe lung infections and was under suspicion for tuberculosis (TB) after a preliminary positive acid-fast bacilli (AFB) result was reported. Despite this, upon the resident's return from the hospital, the facility did not implement appropriate isolation precautions or interventions to prevent potential transmission of communicable diseases. Staff interviews and record reviews revealed that there was confusion and lack of clarity among facility staff regarding the need for isolation and the use of personal protective equipment (PPE) for the resident. The resident was allowed to participate in group activities and dine with other residents, and staff were not consistently wearing N95 masks or following airborne precautions. Multiple staff members, including nurse practitioners, licensed vocational nurses, and the DON, indicated uncertainty about the facility's protocol for handling suspected or confirmed TB cases, especially in the absence of a negative pressure room. The facility's own policies required immediate respiratory isolation and use of PPE for suspected TB cases, but these were not followed. Furthermore, after the facility received notification of a positive AFB result, no post-exposure interventions were implemented for residents or staff who may have been exposed. There was no monitoring for signs or symptoms of infection among those potentially exposed, and no chest x-rays or other assessments were conducted. Communication with the local health department confirmed that the facility was advised to use isolation and N95 masks as a precaution, but these recommendations were not fully enacted. The facility's failure to follow its own infection control policies and to implement necessary precautions placed residents and staff at risk for the development and transmission of communicable diseases.
Failure to Provide Resident Rights and Admission Packet Upon Admission
Penalty
Summary
The facility failed to provide a notice of rights and services to a resident prior to or upon admission, as well as during the resident's stay, and did not ensure receipt and written acknowledgment of such information. The resident in question was admitted with a history of psychoactive substance abuse, traumatic brain injury, and a recent traumatic subarachnoid hemorrhage. Upon admission and subsequent readmission, neither the resident nor the family member received the required admission packet or information regarding resident rights, as confirmed by interviews with the family member, administrator, and other facility staff. The deficiency was further substantiated by staff interviews, which revealed that the admission packet, containing essential information such as resident rights, consent forms, and facility policies, was not provided due to the chaotic circumstances surrounding the resident's behavioral issues. The administrator acknowledged that the admission packet was not given because of the behavioral incidents that occurred shortly after admission. The receptionist, who was responsible for distributing admission packets on weekends, stated she did not receive instructions to provide the packet to the resident or family member during the relevant period. Facility policies reviewed indicated that it is standard procedure to provide residents and their representatives with written information about their rights and services, and to obtain a signed acknowledgment for the clinical record. However, in this case, the process was not followed, and the required documentation was not present in the resident's record. The family member also reported not receiving any incident report or information about the resident's rights, and was not informed about the process for appealing a discharge.
Failure to Provide Admission Packet and Resident Rights Information
Penalty
Summary
The facility failed to establish and implement proper admission policies for a resident who was admitted and subsequently re-admitted following a hospital stay. Upon review, it was found that neither the resident nor the resident's family members completed or signed an admission agreement at the time of admission. The facility did not provide the required admission packet, which includes essential information such as resident rights, facility services, and policies. This omission was confirmed through interviews with the family member, the administrator, the admission coordinator, the receptionist, and the DON, all of whom acknowledged that the admission packet was not given due to the chaotic circumstances surrounding the resident's behavioral issues. The resident in question had a complex medical history, including psychoactive substance abuse, traumatic brain injury, and a recent traumatic subarachnoid hemorrhage with loss of consciousness. Upon admission, the resident exhibited acute mental status changes, including inattention, disorganized thinking, and mood disturbances such as depression, suicidal ideation, and aggressive behaviors. These behaviors led to the resident being sent to the hospital and subsequently returned to the facility, where the situation remained unstable. Interviews revealed that the facility's process for distributing admission packets was not followed. The admission coordinator was responsible for providing packets during weekdays, while the receptionist handled this task on weekends if instructed. However, during the resident's admission, the receptionist did not receive instructions to provide the packet, and the family member confirmed that no admission materials or resident rights information were received. The facility's own policies require that residents and families receive and sign for these documents, but this did not occur in this case.
Failure to Provide Required Written Discharge Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide the required 30-day written notice of discharge to a resident and the resident's responsible party prior to the resident's discharge. The resident, who had a history of psychoactive substance abuse, traumatic brain injury, and impaired cognitive function, was discharged home without the mandated written notification. Documentation shows that the family member was informed verbally and given discharge instructions, but refused to sign the discharge paperwork, stating disagreement with the decision and lack of prior notice. The family member reported not receiving any written 30-day notice or incident report and was told by the administrator that the resident had to leave by the end of the day. Additionally, the facility did not notify the Office of the State Long-Term Care Ombudsman of the resident's discharge as required. The ombudsman confirmed that he was not informed of the discharge and emphasized the importance of timely notification, especially in emergency or unplanned discharges, to ensure advocacy and safe transition for the resident. The facility's practice was to send a list of discharges to the ombudsman once a month, rather than immediately upon discharge, which did not meet regulatory requirements for timely notification. Interviews with facility staff, including an LVN and the administrator, confirmed that the standard procedure of providing a 30-day written notice was not followed in this case. The administrator acknowledged that the notice was not given and that the ombudsman would be notified later as per facility policy. The lack of timely written notice and ombudsman notification was a deviation from both regulatory requirements and the facility's own policy, as documented in the report.
Catheter Bag Not Properly Secured, Leading to Infection Control Deficiency
Penalty
Summary
A deficiency was identified when a resident with an indwelling catheter was observed with their catheter bag lying on the floor instead of being properly hooked to the bed. The resident, a male with a history of diabetes mellitus and cerebrovascular accident, had moderately impaired cognition and was on enhanced barrier precautions. Facility records and care plans specified that the catheter bag should be positioned below the level of the bladder, in a privacy bag, and anchored to the bed or wheelchair to prevent pulling and contamination. Despite these instructions, direct observation revealed the catheter bag on the floor, and a licensed vocational nurse (LVN) was seen entering the room, noticing the issue, and then hooking the bag to the bed. Multiple staff interviews confirmed that catheter bags should never be on the floor due to concerns about cross-contamination and infection control. Staff, including LVNs, RNs, the Assistant Director of Nursing (ADON), Nurse Practitioner (NP), and Director of Nursing (DON), all acknowledged that it was everyone's responsibility to ensure catheter bags were properly hung. It was also noted that the resident had a habit of unhooking the catheter bag when repositioning, which contributed to the issue, but staff reiterated that maintaining proper placement of the catheter bag was necessary to prevent infection.
Failure to Provide Necessary Behavioral Health Services for Resident with Acute Behavioral Symptoms
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of psychoactive substance abuse, traumatic brain injury, and traumatic subarachnoid hemorrhage. The resident exhibited significant behavioral symptoms, including verbalized suicidal ideation, physical aggression, agitation, and wandering. Despite these acute behavioral changes, the facility did not utilize the on-call psychiatric service for evaluation or intervention on the day the behaviors escalated. Interviews and record reviews revealed that the resident was admitted for therapy following an accident and initially showed no behavioral issues. However, on the day in question, the resident became aggressive, was physically combative with staff, expressed suicidal thoughts, and disrupted other residents. Staff attempted to manage the behaviors through redirection and 1:1 supervision, but did not contact the on-call mental health provider, despite having access to this resource. The facility's own behavioral management policy outlined the use of such interventions, but these were not implemented. Multiple staff members, including the Administrator, DON, and nursing staff, confirmed that the on-call mental health service was not contacted. The mental health nurse practitioner and the resident's nurse practitioner both stated that the facility should have reached out for psychiatric support, which could have provided assessment, de-escalation, and medication management. The lack of timely referral to psychiatric services was identified as a failure to follow the resident's care plan and the facility's behavioral management policy.
Failure to Coordinate Care and Ensure Safe Transfers Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's right to be free from neglect by not coordinating care and services with the hospice provider, resulting in a lack of alignment between the facility's and hospice's written plans of care. The resident, a male with advanced dementia, hemiplegia, a history of falls, and multiple comorbidities, was dependent on staff for all activities of daily living and required a mechanical lift with two-person assistance for all transfers, as documented in the facility's care plan and physician orders. However, the hospice plan of care did not specify the need for a mechanical lift and two-person assistance for transfers. On the day of the incident, a hospice aide attempted to transfer the resident from a shower chair to the bed without using the required mechanical lift or obtaining assistance from facility staff, despite being aware of the resident's transfer requirements. The aide reported being unable to locate the sling for the lift and proceeded with the transfer alone. During this process, the resident fell, sustaining a laceration to the forehead and a cervical fracture. The incident was not immediately reported to the facility's charge nurse, and the hospice aide did not call for assistance before or after the fall. Interviews and record reviews revealed that the hospice and facility staff did not routinely share or coordinate care plans, and hospice staff were not consistently included in care plan meetings. The hospice aide admitted to sometimes transferring the resident without assistance due to lack of available staff or equipment. Facility staff were not always aware when hospice staff were providing care, and there was no established process to ensure hospice staff reviewed the facility's care plan or Kardex before providing care. The facility also lacked a fall prevention policy and procedure at the time of the incident.
Failure to Provide Adequate Supervision and Assistance During Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a hospice aide failed to use a mechanical lift and two-person assistance to transfer a resident with significant mobility and cognitive impairments, resulting in a fall. The resident, a male with diagnoses including advanced dementia, cerebral infarction, hemiplegia, contractures, and a history of falls, required total assistance for transfers as documented in his care plan and physician orders. Despite these requirements, the hospice aide attempted to transfer the resident without the mechanical lift and without a second person, leading to the resident falling and sustaining a 2 cm laceration to the forehead and a cervical spine fracture. The incident took place during a transfer from a shower chair to the bed after bathing. The hospice aide did not request assistance from facility staff, even though staff were available and had previously instructed her to seek help for all transfers. The aide later stated she was aware of the need for a mechanical lift and two-person assist but did not use the lift because she could not find the sling and sometimes performed transfers alone when help was unavailable. There was also confusion and lack of coordination between the hospice and facility care plans, with the hospice care plan not specifying the need for a mechanical lift and two-person assist, while the facility care plan and physician orders did. Interviews revealed that the hospice aide and facility staff had inconsistent understandings of the transfer requirements, and the hospice aide admitted to not always following the prescribed procedures. The facility did not have a fall prevention policy in place at the time of the incident, and there was no established process for sharing or coordinating care plans between the facility and hospice staff. The lack of communication and adherence to established transfer protocols directly contributed to the resident's fall and subsequent injuries.
Failure to Coordinate Care for Hospice Resident Results in Fall and Injury
Penalty
Summary
The facility failed to ensure proper coordination of care between its staff and hospice staff for a resident receiving hospice services, resulting in a significant incident. The resident, a male with advanced dementia, hemiplegia, a history of falls, and multiple comorbidities, required total assistance for transfers, specifically with a mechanical lift and two-person assistance as documented in the care plan and physician orders. However, the hospice care plan did not reflect this requirement, and hospice staff were not consistently included in care plan meetings or provided with updated facility care plans. On the day of the incident, a hospice CNA attempted to transfer the resident from a shower chair to the bed without using the mechanical lift and without assistance, despite being aware of the resident's need for such support. The CNA reported being unable to find the sling for the lift and, after informing a facility LVN, was told it was acceptable to proceed with a manual transfer. During this process, the resident fell, sustaining a laceration to the forehead and a cervical spine fracture, which required hospitalization and ICU care. The incident was not immediately investigated by facility administration, and there was a lack of communication regarding the event until hospice staff later reported the failure to use the mechanical lift. Interviews revealed that hospice staff were not routinely invited to facility care plan meetings, and there was no established process for sharing or reconciling care plans between the facility and hospice. The hospice CNA admitted to sometimes transferring the resident without assistance due to lack of available staff or equipment. Facility and hospice staff both acknowledged gaps in communication and coordination, with hospice staff relying on their own care plans, which did not include the mechanical lift requirement, and facility staff not ensuring hospice staff were aware of or following the facility's care plan interventions.
Removal Plan
- The alleged perpetrator will not be returning to the facility.
- Out of cycle QAPI including this plan was presented to the Medical Director by the facility administrator. The medical director did not request changes to the plan.
- The Nursing staff/ current hospice agencies CNAs were in-serviced by facility DON/ADON and Regional Compliance Nurse on how to find the level of assistance required for transfer and mechanical devices required in the kiosk.
- Mechanical lifts were tagged with bright colored sign stating, two people required to operate the lift. This was done by the Maintenance Director. This will give a second opportunity for staff to be reminded prior to using the equipment.
- Facility Charge Nurses were in-serviced by the facility DON on how to read the facility Kardex.
- Current hospice agencies CNAs/facility nursing staff providing services to residents at the facility were in-serviced by the facility DON on how to review the residents Kardex located in the kiosk with the Charge Nurse prior to providing direct care to the residents to ensure that the staff is aware of the number of people required for transfers and use of any mechanical lifts. This will be randomly monitored by DON/ADON/Admin. To prevent the recurrence of falls and injuries.
- The facility Social Worker will be sending reminder emails to contracted hospice agencies to attend the required mandatory care plan meetings at the facility as scheduled. To ensure the coordination of services. This will be randomly monitored by Admin/DON/ADON.
- 100% of residents' records were reviewed to ensure that the information reflected in the Kardex/Care plans for any residents requiring assistance with transfer to include any assistive devices. This was done by DON/ADON and the Regional Compliance Team.
- Facility staff and current hospice agencies were in-serviced by the DON/ADON and compliance nurse on Abuse and neglect. No facility staff member or contract hospice agency staff will be allowed to provide care until receiving the in-service mentioned above.
- Hospice CNAs must sign in upon arrival and review the Kardex with the charge nurse to ensure the plan of care and level of assistance are understood before providing care. Education is posted at the nurse's station.
- All hospice staff must report to charge nurse and review Kardex. All hospice staff must report to the charge nurse upon arrival and review the Kardex before providing care. They must sign off that they have reviewed and understood the Kardex.
- In-service training on identifying and reporting abuse, neglect, and exploitation for hospice staff.
- Training addressed recognizing signs of abuse, neglect, and exploitation and the importance of timely reporting.
Failure to Implement and Follow Neglect Prevention Policies During Resident Transfer
Penalty
Summary
The facility failed to implement and follow written policies and procedures to prohibit and prevent neglect, as well as to investigate allegations of neglect, for a resident with significant cognitive and physical impairments. The resident, a male with advanced dementia, hemiplegia, a history of falls, and multiple comorbidities, required total assistance with transfers using a mechanical lift and two staff members, as documented in his care plan and physician orders. Despite these requirements, a hospice aide transferred the resident without the mechanical lift and without two-person assistance, resulting in a fall that caused a laceration to the forehead and a cervical fracture. The incident occurred when the hospice aide, unable to locate the mechanical lift sling, proceeded to transfer the resident with the help of an LVN, but without the required equipment. After the shower, the aide attempted to transfer the resident back to bed alone, again without the mechanical lift or assistance, during which the resident fell from the bed. The aide admitted to not following the required transfer protocol and not seeking help, despite being aware of the resident's needs. The facility staff, including the LVN and the administrator, were not aware of the improper transfer until after the incident, and the administrator did not initiate an investigation into the cause of the fall as required by the facility's abuse/neglect policy. Additionally, there was a lack of coordination and communication between the facility and hospice staff regarding the resident's care plan and transfer requirements. The hospice care plan did not document the need for a mechanical lift and two-person assistance, and hospice staff were not included in the facility's care plan meetings. The facility's policies required all reports or suspicions of neglect to be investigated, but this was not done in this case. The failure to implement and follow these policies and procedures placed the resident at risk of not receiving necessary care and services.
Failure to Investigate and Prevent Neglect During Resident Transfer
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated, specifically in the case of a male resident with significant cognitive and physical impairments. The resident, who had diagnoses including advanced dementia, cerebral infarction, hemiplegia, and a history of falls, required total assistance with transfers using a mechanical lift and two staff members, as documented in his care plan and physician orders. Despite these requirements, a hospice aide transferred the resident without the mechanical lift and without adequate assistance, resulting in a fall that caused a laceration to the forehead and a cervical fracture. The incident occurred when the hospice aide, unable to locate the sling for the mechanical lift, proceeded with the transfer with only one staff member and without the required equipment. The aide admitted to not always using the mechanical lift and sometimes transferring the resident alone due to lack of available help. Facility staff, including the LVN, were aware of the resident's care needs but did not ensure the proper transfer method was used. The event was not immediately or thoroughly investigated by the facility administration, and the administrator was unaware of the improper transfer until informed by hospice staff days later. There was no evidence that the facility initiated an investigation into the cause of the fall or monitored adherence to care plan interventions for transfers. Additionally, there was a lack of coordination and communication between the facility and hospice staff regarding the resident's care plan. Hospice staff did not have the updated care plan reflecting the need for a mechanical lift and two-person assistance, and they did not participate in the facility's interdisciplinary care plan meetings. The facility's policy required all reports or suspicions of abuse or neglect to be investigated, but this protocol was not followed in this case, as the administrator did not begin an investigation or ensure protective measures were in place during the process.
Failure to Suspend Staff Following Abuse Allegation
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically in the case of one resident who alleged that a night nurse had hit him on the chest and acted aggressively. The resident, a male with a history of pulmonary hypertension, right-sided heart failure, and episodes of syncope, reported that a male night nurse matching the description of a staff member had struck him. Multiple staff interviews confirmed that the description provided by the resident matched a specific LVN, who was working during the relevant period. Despite the facility's abuse policy requiring immediate suspension of any employee identified as an alleged perpetrator pending investigation, the LVN in question was not promptly suspended after being identified. Interviews with the DON, HR, and the Ex-Administrator revealed inconsistencies and lack of documentation regarding the LVN's suspension. HR could not find any record of a suspension, and timesheets indicated the LVN continued to work during the period in question. The Ex-Administrator and other staff acknowledged that the LVN matched the resident's description and that policy required suspension, but this was not consistently or clearly carried out. The facility's own abuse and neglect policy states that employees alleged to have committed abuse must be immediately suspended pending investigation to protect residents. However, the investigation summary and provider action taken did not reflect this requirement, and the LVN continued to work, only being removed from the specific resident's care after the investigation. Staff interviews confirmed awareness of the policy but also highlighted a failure to follow it, as the LVN was not suspended as required when first identified as the alleged perpetrator.
Failure to Timely Report Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that alleged violations involving misappropriation of resident property were reported immediately to the administrator and to the state agency, as required by both facility policy and state law. Specifically, when a resident with impaired cognition, legal blindness, anxiety, and major depressive disorder reported missing money from his wallet, the initial report was made by a CNA to an LVN, and subsequently to the DON and ADON. However, the administrator was not notified immediately, and the incident was not reported to the state agency within the required timeframe. Interviews revealed that the CNA and LVN were aware of the resident's claim of missing money and had recounted the funds on two separate occasions, noting a decrease from $84 to $34. The DON and ADON acknowledged receiving the report from staff but did not promptly inform the administrator or ensure that the state agency was notified. The social worker was conducting an investigation, but the reporting process was not followed as outlined in the facility's abuse and neglect policy. The administrator confirmed that he was not made aware of the missing money until much later and that, had he been notified, he would have followed the facility's abuse protocols. The facility's policy clearly states that all allegations of abuse, neglect, exploitation, or misappropriation of property must be reported to the administrator and the state agency within specified timeframes. The failure to report the incident as required constituted a deficiency in the facility's handling of suspected misappropriation of resident property.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for two residents, leading to a deficiency in accommodating resident needs and preferences. Resident #49, a cognitively impaired female with a traumatic brain injury and other mental health issues, was found without a call light connected to the wall near her bed. She was unable to understand or use the call light due to her cognitive impairments. This lack of access to a call light placed her at risk of being unable to contact staff for assistance. Similarly, Resident #68, a male with Huntington's chorea and cognitive impairments, was observed with his call light on the floor, out of reach. Despite having a history of dropping the call light, the facility did not ensure it was consistently within his reach. The CNA noted that the resident had previously used a different type of call light but was unable to operate it effectively. The absence of a reachable call light for Resident #68 increased the risk of unmet needs, as he was nonverbal and unable to call for help.
Lack of Private Phone Call Area for Residents
Penalty
Summary
The facility failed to ensure that residents had reasonable access to a private area for making telephone calls, which compromised the privacy rights of two residents. Resident #63, a cognitively intact female with a history of Type 2 diabetes, hypertension, and schizoaffective disorder, was observed making a phone call in a public hallway where other residents and staff were nearby. She expressed dissatisfaction with the lack of a private space for phone calls, noting that a previously available private area had been repurposed, leaving her to make calls in public areas. Similarly, Resident #94, a cognitively intact male with Parkinson's disease, bipolar disorder, and sleep apnea, was observed making a phone call at the nurses' station, surrounded by staff and other residents. He indicated a preference for a more private setting due to difficulties hearing over the noise in the lobby area. Interviews with staff revealed that there was no designated private area for phone calls, and residents typically used phones in hallways or at the nurses' station, with the option to request a cell phone from the Social Worker for use in their rooms. The Director of Nursing acknowledged the lack of a designated private area and stated that staff were expected to redirect residents to private spaces for phone calls. However, the facility's attempts to provide a private phone area had been unsuccessful, as a previous space was converted into a chapel, and technical issues prevented the installation of a phone line. The facility's policy on resident rights emphasized the importance of providing a private area for phone calls, which was not being adhered to, resulting in the deficiency.
Privacy Breach in Resident Communications
Penalty
Summary
The deficiency involves a failure to maintain the privacy and confidentiality of residents' personal and medical records. Specifically, the report highlights that residents have the right to reasonable access to telephones, including TTY and TDD services, and a private space to make calls without being overheard. This includes the right to retain and use a cellular phone at their own expense. The report mentions two residents in relation to privacy concerns, indicating a breach in maintaining the confidentiality of their communications and personal information.
Improper Food Handling and Cross-Contamination Risk
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the actions of a dietary aide. The aide used a pitcher that had been placed on an unsanitized black cart to refill it with tea by scooping from a tea container, then poured the tea into cups for serving. This practice was observed multiple times, with the pitcher being placed back on the black cart, which was noted to have white sugar-like dirt particles and stains. The unsanitized cart posed a risk of cross-contamination, as confirmed by the Kitchen Director and the dietary aide, both of whom acknowledged the potential for foodborne illness due to improper sanitation practices. Interviews with the Kitchen Director and the Administrator revealed that training on cross-contamination and food safety was provided during hire and annually, with additional monitoring by the dietitian and dietary consultant. Despite these measures, the dietary aide's actions demonstrated a lapse in following the facility's sanitation and food handling policies, which require work surfaces to be kept clean during preparation and service. The Administrator highlighted the primary risks associated with such deficiencies, including foodborne illnesses and bacterial infections, which could arise from improper handling or contamination, such as bacteria transferred from the unsanitized cart.
Infection Control Lapses in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving improper use of personal protective equipment (PPE) and hand hygiene. In the first incident, a Certified Nursing Assistant (CNA) performed incontinent care for a resident with Alzheimer's disease and dementia without changing gloves between handling soiled and clean items. The CNA used the same gloves to wipe the resident's vaginal and rectal area and then proceeded to handle clean items, such as a new brief and bed sheets, without sanitizing her hands. This oversight was acknowledged by the CNA, who admitted to forgetting the proper procedure due to nervousness. In the second incident, a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) failed to use the required PPE during medication administration via a PEG tube for a resident on Enhanced Barrier Precautions (EBP). Despite the presence of a sign indicating the need for gloves and gowns for high-contact activities, both staff members only sanitized their hands and wore gloves, neglecting to don gowns and face masks. Both the LVN and ADON admitted to forgetting the EBP requirements, attributing their lapse to nervousness and unfamiliarity with the resident's care routine. These deficiencies were identified through observations and interviews with the involved staff, the Director of Nursing (DON), and the facility Administrator. The DON and Administrator both acknowledged the lapses in infection control practices, noting that the staff had received training on proper procedures. However, the incidents highlighted a failure to consistently apply these practices, potentially placing residents at risk of infections.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of practice for the care of a midline in a resident requiring intravenous therapy. Specifically, the facility did not change the PICC line dressing for a resident as ordered by the physician. The resident, a male with a history of sepsis, hemiplegia, muscle weakness, and cognitive communication deficit, was admitted with a PICC line that required dressing changes every seven days. However, during an observation, it was noted that the dressing had not been changed since 12/08/24, despite being due for a change on 12/15/24. The resident expressed discomfort and had been waiting for the dressing to be changed, although no signs of infection were observed at the site. Interviews with facility staff, including an RN, ADON, and DON, revealed that the responsibility for changing the PICC line dressing fell to the charge nurses, who were expected to follow physician orders and facility policy. The staff acknowledged the risk of infection if the dressing was not changed as required, although no immediate signs of infection were present. The facility's policy outlined that PICC line dressings should be changed every seven days or as needed, and the failure to comply with this protocol was identified as a deficiency in the care provided to the resident.
Deficiency in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, leading to a deficiency in medication management. The resident, who had a moderately impaired cognitive status, was found with over-the-counter Selenium and Aspirin at his bedside without any assessment for self-administration. The resident was unable to articulate the purpose of these medications and could not recall when they were last taken. The facility's records showed no orders for these medications, and there was no care plan addressing self-medication administration for the resident. Interviews with staff revealed that the resident had a history of possessing unauthorized over-the-counter medications, and although redirection and education were provided, the issue was not reported to upper management until later. The facility's policy required an assessment to determine a resident's ability to self-administer medications safely, which was not conducted in this case. Staff were expected to monitor and remove unauthorized medications during rounds, but this was not effectively implemented, leading to the deficiency in ensuring medication safety for the resident.
Failure to Secure Treatment Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with the treatment cart on hall 200. During an observation, the treatment cart was found unlocked and unsupervised, containing several needles, dressings, and medicated ointments. LVN A admitted to leaving the cart unlocked when she stepped away to check on a resident with the doctor present, acknowledging that she normally locks the cart but forgot on this occasion. Interviews with the Director of Nursing (DON) and the Administrator confirmed that it is expected for medication or treatment carts to be locked when not in use or under direct supervision. Both acknowledged that leaving the cart unlocked could allow unauthorized access to its contents by staff, family members, or residents. The facility's policy from 2003 also indicated that carts must be locked when not in use or under direct supervision.
Inaccurate Documentation of PICC Line Dressing Change
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident, identified as Resident #27, who was admitted with diagnoses including sepsis, hemiplegia, muscle weakness, and cognitive communication deficit. The resident's care plan required a PICC line dressing change every seven days. However, RN C documented that the dressing change was completed on a specific date, despite not performing the task. This discrepancy was discovered during an observation where the dressing was found to be dated several days earlier, and the resident reported waiting for the dressing change. Interviews with RN C, the ADON, the DON, and the Administrator revealed that the facility had protocols and training in place to prevent such documentation errors. RN C admitted to signing off on the task without completing it, acknowledging the training received on accurate documentation. The ADON and DON highlighted the risks of assuming tasks were completed based on inaccurate documentation, which could lead to inadequate care. The facility's documentation policy emphasized the importance of maintaining complete and accurate records, but the failure to adhere to this policy resulted in a deficiency.
Conflicting Transfer Instructions in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, leading to conflicting transfer instructions. The resident, a male with a history of physical injury, repeated falls, and various mobility issues, was admitted and re-admitted to the facility earlier in the year. His care plan included conflicting instructions for transfers, specifying both a two-person transfer with a mechanical lift and a one-person transfer, which were implemented simultaneously. The deficiency was identified through observations, interviews, and record reviews. The resident's care plan dated June 5th indicated the need for a two-person Hoyer lift for transfers, yet staff were observed using different methods, including a gait belt. Interviews with staff revealed confusion and inconsistency in the transfer methods used, with some staff unaware of the correct procedure. The Regional MDS and other staff acknowledged the risk of injury due to the conflicting care plan instructions. The facility's comprehensive care planning policy requires the development of a person-centered care plan with measurable objectives and timeframes. However, the failure to update and communicate the correct transfer method for the resident led to a fall incident, as noted in the resident's event note. The facility's preventive strategies to reduce fall risk emphasize individualized care plans, but the inconsistency in the resident's care plan posed a risk of injury, as confirmed by multiple staff members during interviews.
Improper Transfer and Unreported Fall in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident, who required a two-person transfer with a mechanical lift, was transferred appropriately. Instead, the resident was transferred by a single CNA using a gait belt, which was not in accordance with the resident's care plan. This improper transfer led to the resident's right leg getting caught between the wheelchair and bed, resulting in a fall where the resident hit the floor and experienced pain. The resident, identified as having a history of repeated falls, muscle weakness, and poor safety awareness, was not provided with the necessary supervision and assistance during the transfer. The care plan for the resident was inconsistent, with conflicting instructions regarding the number of staff required for transfers. Despite the resident's complaints of pain following the fall, the incident was not reported to the nursing staff, and no immediate assessment was conducted. Interviews with facility staff revealed a lack of communication and adherence to the resident's care plan. The CNA involved admitted to not reporting the incident, and there was confusion among staff regarding the correct transfer method for the resident. The facility's policies on event reporting and safe transfer procedures were not effectively implemented, contributing to the deficiency in care provided to the resident.
Failure to Ensure Residents Are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Specifically, the facility did not obtain consent, a physician's order, or a care plan for a resident's full bed rails, which restricted the resident's movements. The resident, who had severe cognitive impairment and required total assistance with bed mobility and transfers, was observed lying on a bed with raised full side bed rails without any documentation indicating the necessity of these restraints for medical symptoms. The resident's medical history included atrial fibrillation, CVA with right-sided deficits, dementia, depression, and seizures. Despite these conditions, there was no documentation in the resident's care plan or order summary regarding the use of bed rails. The bed with full side rails was provided by Hospice, and facility staff, including an RN and the DON, were unaware of the need for an order for the bed rails. The bed had been in use for about a month without proper authorization or documentation. Interviews with facility staff revealed a lack of awareness and understanding regarding the use of bed rails as restraints. The DON and Administrator both stated that full side bed rails were not allowed at the facility as they could be considered restraints. The facility's policy on restraints emphasized that restraints should only be used with a physician's order, informed consent, and a care plan, none of which were in place for the resident. The facility had previously received a citation on restraints and had in-serviced staff on identifying and reporting restraint issues, yet the bed rails remained in use for an extended period without proper oversight.
Failure to Maintain Infection Control for Covid-19 Isolated Resident
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, specifically for a resident who was isolated for Covid-19. The resident, a [AGE] year-old female with diagnoses of COPD, asthma, and schizoaffective disorder, had a severely impaired cognitive status as indicated by a BIMS score of 4. Despite being isolated for Covid-19, observations on multiple occasions revealed that the resident's door was wide open, contrary to the facility's policy and training that required Covid-19 isolated rooms to have their doors closed to prevent cross-contamination and infection spread. Red tape and signs indicating the need for the door to be closed were present but not adhered to by the staff. Interviews with multiple CNAs, a Med Tech, and the DON confirmed that all staff had received training on Covid-19 precautions, which included keeping the doors of Covid-19 isolated rooms closed. Despite this training, the staff failed to ensure that the resident's door remained closed, thereby increasing the risk of cross-contamination and infection. The facility's policy on patient placement during the Covid-19 pandemic also explicitly stated that doors should be kept closed for patients with suspected or confirmed SARS-CoV-2 infection, which was not followed in this case.
Failure to Ensure Proper Catheter Care
Penalty
Summary
The facility failed to ensure that two residents with indwelling catheters received appropriate treatment and services to prevent urinary tract infections and to secure their catheters properly. Resident #16, a [AGE] year-old female with severe cognitive impairment and multiple medical conditions, was observed without a catheter leg strap, contrary to her care plan and physician orders. The absence of the catheter strap posed a risk of the catheter being pulled out, causing pain and discomfort. RN C confirmed the lack of the catheter strap and acknowledged the associated risks during an interview. Similarly, Resident #17, a [AGE] year-old male with severe cognitive impairment and an indwelling catheter, was observed with his catheter drainage bag lying on the floor and without a catheter strap. This was against the care plan instructions to keep the drainage bag off the floor and ensure the catheter strap was in place. RN C confirmed the observations and acknowledged the risks of infection and catheter trauma. The Director of Nursing (DON) also confirmed that the drainage bag should not be on the ground and highlighted the risks of contamination and infection due to improper catheter care practices.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grace Pointe Wellness Center | 1.1 mi | ★★★★★ | 22 | 0 |
| Mountain Villa Nursing Center | 2.6 mi | ★★★★★ | 27 | 0 |
| Nazareth Living Care Center | 4.1 mi | ★★★★★ | 19 | 0 |
| Franklin Heights Nursing & Rehabilitation | 4.2 mi | ★★★★★ | 9 | 0 |
| The Montevista At Coronado | 4.7 mi | — | 0 | 0 |
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