Failure to Honor Guardian’s Request and Physician Order for PRN Psychotropic Medication Sequence
Summary
The deficiency involves the facility’s failure to honor a court-appointed guardian’s request and a physician’s order regarding the sequence of administering PRN psychotropic medications for a resident with a traumatic brain injury, depression, anxiety, and behavioral disturbances. The guardian, based on her observations, preferred that PRN Ativan be administered first for the resident’s aggressive and yelling behaviors, and only if ineffective, that PRN Trazodone be used, as Trazodone made the resident appear sleepier rather than improving behavior. This preference was communicated to the DON on 02/05/26, documented in a nurse’s progress note, and relayed to the physician, who issued an order specifying that Ativan should be tried first before Trazodone. Facility policies stated that residents or their legal representatives have the right to participate in care planning, that medications must be administered in accordance with prescriber orders, and that psychotropic medication management is an interdisciplinary process involving the resident and representative. Despite the guardian’s request and the explicit physician’s order to try Ativan first, MAR reviews for February and March 2026 showed multiple instances where PRN Trazodone was administered without a prior trial of PRN Ativan, or where Trazodone was given earlier in the day and Ativan only later, contrary to the ordered sequence. Specific dates documented repeated administration of Trazodone alone or before Ativan. In interviews, two nurses acknowledged they were aware of the guardian’s request and the order to use Ativan first, yet they administered Trazodone prior to Ativan, with one nurse stating she believed Trazodone was more effective. The DON confirmed that the expectation was for all nurses to follow physician orders, including directions, but the documented medication administration patterns and staff interviews demonstrated that the order and the guardian’s expressed preferences were not consistently followed.
Penalty
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A resident with severe cognitive impairment, dementia, blindness, and full-care needs had no listed family or representative in the record, and staff reported no known visitors or guardian. The SW said guardianship had not been pursued, while the DON and NP acknowledged the resident could not make care decisions and that no orders designated a guardian or representative. The facility’s Resident Rights policy stated that the resident has the right to have a legal representative.
A resident with impaired cognition had a family member designated as POA with authority over health care and related decisions. The POA, concerned about the resident’s care, repeatedly requested the resident’s medical records but was directed to Medical Records and required to complete written forms, unlike residents who could obtain records via oral request. The POA initially completed the form incorrectly and was told to redo it; the corrected paperwork was not submitted until after the resident’s death, at which point additional documentation was required. Staff, including MR personnel, acknowledged that the POA was authorized to act for the resident and that the resident lacked capacity to request records independently, yet the POA never received the records, resulting in a failure to allow the representative to exercise the resident’s rights.
A resident with dementia, ESRD on dialysis, impaired vision, and a severely impaired BIMS score had a designated responsible party, but the facility’s BOM bypassed this representative and obtained the resident’s signature on a retirement income address‑change form so the facility could receive pension checks directly. The BOM did not verify the resident’s cognitive status or consult the MDS nurse, despite acknowledging that low BIMS scores indicate inability to make informed decisions and that policy requires the representative’s signature. The resident’s representative, who worked part‑time at the facility, reported she was not contacted, questioned the authenticity of the printed signature, and stated the resident could not make such financial decisions. A CNA reported she did not witness the resident sign the form and described the resident’s cognition as poor, while the Administrator maintained that the resident could make his own decisions regardless of the low BIMS score, resulting in the facility failing to honor the representative’s authority.
Failure to Refer Incapacitated Resident for Patient Representative: A resident with bipolar disorder, anxiety disorder, and schizoaffective disorder was documented by the H&P as lacking capacity to understand and make decisions, while the admission record listed the resident as self-responsible. The SSD stated the resident had no family or designated decision-maker and was never referred to OLTCPR, despite facility policy requiring notification when no representative could be found. The DON stated the resident needed a representative, such as a family member, friend, or OLTCPR appointee, to assist with medical decisions and care oversight.
A resident with severe cognitive impairment and Korsakoff’s dementia repeatedly engaged in close physical and sexualized contact with another resident, including hand-holding, kissing, wandering together, attempts to leave the unit, and being found in the other resident’s bed with his pants unbuttoned and exposed. The resident’s daughter, acting as POA and documented decision maker, had clearly and repeatedly instructed staff that she did not want her father around the other resident and that any contact between them should not be permitted or encouraged. Despite these directives, staff continued to allow the two residents to be together, and the POA found them sitting closely together and holding hands after the bed incident, while leadership acknowledged that the two residents were always together and that the other resident was considered too difficult to redirect.
A resident with a history of subarachnoid hemorrhage, cognitive communication deficit, encephalopathy, and documented moderate memory impairment underwent extensive surgical dental extractions without informed consent from the identified Responsible Party (RP). The physician’s orders indicated the resident lacked capacity, and the face sheet listed a family member as RP, yet consent was reportedly obtained from the resident instead. The DON confirmed no RP consent could be located, and a dental hygienist stated they normally contact the RP but were unaware of the RP status and had never spoken with the family member.
Failure to verify authority of resident representative
Penalty
Summary
The facility failed to obtain documentation showing that Resident #13’s representative had been delegated the authority to exercise the resident’s rights, and it did not verify that any court-appointed representative had authority for the specific decision-making at issue. Resident #13 was admitted with diagnoses including cerebral infarction, bipolar disorder, schizoaffective disorder, altered mental status, legal blindness, malignant neoplasm of the larynx, dementia, and cognitive communication deficit. The record showed severe cognitive impairment, with a BIMS score of 02, and the care plan stated that he had impaired cognition, was at risk for further decline, and needed supervision and assistance with all decision making. The resident’s face sheet did not list any family members or resident representatives. A progress note stated that he was a new admit, was blind, required full care, and had no family member listed on the admission sheet. During observation, Resident #13 was lying in bed and did not respond to the surveyor’s questions. CNA staff stated they had never seen him have visitors and were not aware of any family members or resident representative. The social worker stated that the facility had not pursued guardianship, that care plan meetings were held in the resident’s room, and that the resident did not participate because he could not make decisions for himself. The DON stated that a resident who cannot communicate should have a guardian or representative to inform staff of the resident’s wishes and for proper care, and that if there is no family or representative, the facility must reach out to the physician to make sure the resident has a representative. The NP stated that Resident #13 could communicate immediate needs but not make decisions about care plans or activities, had no known family members or guardians, and that there were no orders designating anyone as guardian or representative. The facility’s Resident Rights policy stated that the resident has the right to have a legal representative.
Failure to Honor Resident’s POA Request for Medical Records
Penalty
Summary
The facility failed to allow a resident’s designated representative, who held power of attorney (POA), to exercise the resident’s rights by obtaining the resident’s medical records. The resident had impaired cognitive function with a BIMS score of 5 and had formally designated a family member as POA effective 12/24/24, with authority over long‑term placement, health care, mental health including medications, and hospitalizations. According to the state agency complaint intake, the POA was concerned about the care the resident was receiving and requested the resident’s medical records before the resident passed away, but the facility never provided them. A nursing progress note documented that the POA approached the ADON and staff, stating she was still waiting on medical records and needed to sign whatever was required to obtain them, and expressed that the delay was unacceptable. Interviews and record review showed that the facility’s process for releasing records created a barrier for the POA, despite staff acknowledging her authority and the resident’s lack of capacity to request records independently. LPN #1 stated that family members requesting medical records had to go to Medical Records (MR). The MR staff confirmed that the POA requested the records and was given paperwork to complete on two occasions; the first form was filled out incorrectly, and the POA was told to redo it. MR reported that the corrected paperwork was not returned until after the resident died, at which point the facility required additional paperwork to release records after death. MR also acknowledged knowing that the POA could act on the resident’s behalf and that, unlike a resident’s oral request, the POA was required to complete written forms. As a result, the POA never obtained the resident’s medical records.
Failure to Honor Resident Representative’s Authority in Financial Decision‑Making
Penalty
Summary
The deficiency involves the facility’s failure to recognize and honor the authority of a resident’s representative in financial decision‑making, despite the resident’s severe cognitive impairment. The resident was a 97‑year‑old male with dementia, end‑stage renal disease requiring dialysis, restlessness and agitation, hypertension, impaired vision, and a BIMS score of 3 indicating severe cognitive impairment. His care plan identified impaired cognitive function/dementia and directed staff to monitor and report changes in decision‑making ability and mental status. The face sheet listed a family member as the responsible party. During observation, the resident appeared flustered, had difficulty hearing, and was unable to understand and respond to surveyor questions, making interview attempts unsuccessful. The Business Office Manager (BOM) learned from the state that the resident had additional retirement income, which increased his monthly liability for room and board and resulted in an outstanding balance. The BOM reported that the responsible party had been keeping the extra retirement check and had entered into a promissory note to pay the balance. Instead of obtaining the responsible party’s signature, the BOM approached the resident directly in the hallway with a retirement income address‑change form so the facility could receive the retirement checks. The BOM stated she assumed the resident could make his needs known and did not verify the resident’s BIMS score or consult the MDS nurse, despite acknowledging that a low BIMS score would indicate the resident was not cognitively able to make an informed decision and that policy and procedure required obtaining the responsible party’s or appointed family member’s signature. The resident’s representative reported she did not understand why the BOM did not contact her at the facility where she worked part‑time and stated she believed the resident could not make such financial decisions due to his BIMS of 3. She also questioned the authenticity of the resident’s signature on the address‑change form, noting that the signature was printed while the resident normally signed in cursive. The BOM claimed a CNA had witnessed the signature, but the CNA stated she never saw the resident sign the form and only saw the BOM later waving the paper and saying she had obtained a signature. The CNA also described the resident’s cognitive status as poor, with difficulty remembering recent events and uncertainty about whether he could understand what he was signing. The Administrator stated that the resident could make decisions for himself regardless of the low BIMS score and that the state would have to deem a resident incompetent by court for the facility to take over financial responsibility, reinforcing that the facility treated the resident’s signature as valid rather than deferring to the designated representative.
Failure to Refer Incapacitated Resident for Patient Representative
Penalty
Summary
The facility failed to submit a referral to the Office of the Long-Term Care Patient Representative (OLTCPR) for one sampled resident who lacked decision-making capacity and had no legally authorized decision-maker. Resident 28 was admitted with diagnoses including bipolar disorder, anxiety disorder, and schizoaffective disorder. The admission record identified the resident as self-responsible, while the History and Physical stated the resident did not have the capacity to understand and make decisions. The Minimum Data Set also documented delusions and assistance needs with multiple activities of daily living. During interview, the Social Services Director stated that when a physician determined a resident lacked capacity, the facility would first try to locate next of kin or another decision-maker, and if none was available, a referral would be sent to the OLTCPR. The Social Services Director also stated the resident would be placed under the bio-ethics committee while waiting for a representative. However, the Social Services Director acknowledged that Resident 28 did not have the capacity to make medical decisions when admitted and was never referred to the OLTCPR. The Director of Nursing stated that when a resident lacked the capacity to understand or make decisions, the facility was responsible for ensuring the resident had a representative, such as a family member, friend, or an appointed representative from the OLTCPR. The facility policy titled Lack of Capacity Process stated that after 72 hours, if no patient representative could be found, the facility would notify the Office of Patient Representative to assign one. The California Department of Aging webpage cited in the report stated that OLTCPR provides trained public representatives for residents who lack decision-making capacity and have no legally authorized surrogate.
Failure to Honor POA Decisions Regarding Resident-to-Resident Physical/Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s legal representative was able to exercise decision-making rights regarding the resident’s physical and sexual contact with another resident. Resident 12, who had Korsakoff’s dementia and was assessed as severely confused but independently ambulatory, had a documented power of attorney (POA) held by his daughter, identified as Family Member 1. Clinical records showed repeated instances of close physical contact between Resident 12 and Resident 11, including hand-holding, kissing, walking together, and attempts to leave the unit together. A quarterly MDS dated March 18, 2026, confirmed Resident 12’s severe cognitive impairment. Nursing notes from December 14 and December 29, 2025, documented that Resident 12 was talking with, holding hands with, kissing, and wandering the unit with Resident 11, and that they were trying to leave the unit together. On March 12, 2026, a nurse’s note documented that Resident 12 was found in Resident 11’s bed next to her with his pants unbuttoned and exposed. When the facility notified his daughter/POA, she was angry because she had previously been told that the residents would be separated. In an interview, Family Member 1 stated that in early December, shortly after admission, staff had informed her that Resident 11 had attached herself to Resident 12 like he was her boyfriend, and she clearly communicated that she did not want her father around Resident 11 due to his age and marital status. She reported that during multiple visits, Resident 11 followed them and told Resident 12 they needed to leave together, and that she had explicitly requested that they be separated and that contact between them not be permitted or encouraged. Despite this, when she arrived at the facility after the March 12 incident, she found Resident 12 sitting with Resident 11 at the nurse’s station, holding hands with her head on his shoulder. The Assistant DON confirmed that Resident 11 believed Resident 12 to be her boyfriend, that they were always together, and that although the daughter did not want them together, staff found Resident 11 too difficult to redirect.
Failure to Obtain Informed Consent from Responsible Party for Extensive Dental Extractions
Penalty
Summary
The deficiency involves the facility’s failure to obtain informed consent from a resident’s Responsible Party (RP) prior to extensive dental extractions. The resident had diagnoses including subarachnoid hemorrhage, cognitive communication deficit, encephalopathy, and long-term use of anticoagulants, and an MDS dated 2/5/26 documented moderate memory impairment. The physician’s orders indicated the resident was not capable, and the nurse practitioner note from 3/31/26 stated the resident was awake but had periods of confusion. The face sheet identified a family member as the RP. Despite this, the resident was scheduled on a dental visit list for surgical extraction with bone removal of multiple teeth, and post-operative documentation showed that oral surgery was completed on 4/7/26. During a telephone interview, the RP stated they were not asked for consent for the extractions and that the facility reported obtaining consent directly from the resident, even though the resident was confused at times. On observation, the resident demonstrated memory problems and was unable to answer all questions posed by the nurse surveyor. The DON confirmed that, based on the face sheet and physician’s order indicating no capacity, the RP should have been contacted for consent and that no consent from the RP for the extraction of 21 teeth could be found. A registered dental hygienist reported that they normally call the RP if there is one but stated they did not realize the RP had changed and had never spoken to the identified RP. When requested, the facility was unable to provide a policy and procedure related to this issue.
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