Bellflower Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bellflower, California.
- Location
- 9710 E. Artesia Ave, Bellflower, California 90706
- CMS Provider Number
- 055408
- Inspections on file
- 31
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Bellflower Post Acute during CMS and state inspections, most recent first.
Dirty Ice Machine Used for Resident Ice Service: The facility failed to keep the ice machine clean for sanitary operation. During kitchen observation, surveyors found white-colored matter in the ice chute, black-colored matter on the housing wall, and white-colored matter on the submerged feed water collection basin used to make ice. The DS stated the machine was not clean and that residents can get sick from dirty ice. Facility records showed most residents were subject to receiving ice from the machine, and the facility policy and manufacturer manual required the ice machine and storage bin to be kept sanitary.
Failure to Implement QAPI Corrective Action Planning: The facility failed to follow its QAPI process by not providing documented corrective action plans or performance improvement activities for active QAPI topics including falls, pressure injuries, and legionella water management. The ADM stated interventions for falls and pressure injuries were handled on an individual level, but no facility-level documented plans were provided. The facility's QAPI policy required data-driven monitoring, identification of problems, and development of corrective action plans or performance improvement activities.
A resident with legal blindness, deafness, congenital Rubella Syndrome, and no decision-making capacity had a call light wrapped around the wall plug instead of within reach. The resident required extensive assistance with ADLs, and the care plan included keeping the call light within reach. An LVN and an RNS stated the call light should always be accessible, and the facility policy required staff to keep it within easy reach.
Failure to Offer Advance Directive Information: The facility did not ensure that three residents or their RP were offered or educated about the right to formulate an advance directive. Records showed one resident with dementia and severe cognitive impairment, one resident with acute respiratory failure, UTI, and osteomyelitis, and one resident with cerebral palsy, pneumonia, and cancer; each had documentation that was blank or did not show advance directive education or acknowledgement, despite facility policy requiring written information on admission.
Incomplete SNF ABN forms were not explained in a way two residents understood. Two residents with intact cognition and capacity to make decisions received NOMNC/SNF ABN paperwork, but the ABNs did not show which option they chose for continued skilled services or who would pay the bill. Both residents stated they did not understand the charges, and the BOM confirmed the forms were incomplete and that it was their responsibility to explain the notice and ensure the resident understood it.
Failure to identify and monitor abdominal binder as a restraint: A resident with quadriplegia, dementia, and a G-tube was observed with an abdominal binder and splint in place. The OSR ordered the binder to prevent pulling out the G-tube, but the RNS stated there was no order to assess skin under the binder every 2 hours and no documentation of monitoring. The MDSC did not recognize the binder as a restraint, and the DSD stated the consent was incomplete and staff failed to identify, assess, monitor, and document the restraint use.
Inaccurate MDS coding for abdominal binder restraint. A resident with quadriplegia, dementia, and no decision-making capacity was observed with an abdominal binder in place, while the OSR directed it be worn at all times to prevent G-tube pulling. The MDS Section P stated no trunk or limb restraints were in use, and the MDSC said she did not realize the binder could be considered a restraint because it limited access to the resident’s body and could not be removed independently.
Incomplete Antibiotic Care Planning and Abdominal Binder Care Plan Failure A resident with ESRD, dialysis dependence, and cellulitis received gentamicin for an ear infection, but the chart lacked a care plan for the antibiotic therapy. Staff stated the resident needed a care plan so monitoring, the treatment plan, and evaluation of effectiveness would be clear. A second resident with quadriplegia, dementia, and a G-tube had an abdominal binder ordered to prevent tube removal, but staff did not follow the care plan’s skin checks and monitoring interventions. Interviews and record review showed no documentation of the required assessment and monitoring of binder use.
Failure to Provide Communication Support for a Spanish-Speaking Resident: A resident with no decision-making capacity and multiple care needs was identified in the care plan as at risk for impaired communication, with a communication device planned to help meet needs. During observation, the resident tried to speak Spanish, but CNA staff could not understand her, no communication board was at the bedside, and the CNA stated she did not know how to use the language translating service. A payroll staff member later translated, and facility leadership stated the translation service access details were not available to staff and the communication board had not been provided.
A crash cart by Nursing Station 1 was observed unattended with the key left in the lock, while glucose gels and normal saline syringes were stored inside. An LVN stated the key was always left in place for emergencies, while an RNS stated these items are medications and only licensed staff should have access. Facility policy required medication carts and supplies to be locked or attended by authorized persons.
Food Served Bland and Lukewarm for Multiple Residents: A resident with DM and dysphagia, another resident with hypertension and acute kidney failure, and a third resident with blindness, deafness, CRS, and dysphagia all reported or were observed receiving meals that were bland, unappetizing, or not served at the preferred temperature. One resident refused to eat breakfast, another said hot food was often lukewarm or cold and skipped meals at times, and a third shut his mouth tightly during feeding after tasting bland pureed items. The DS also agreed the carrots and pureed items were bland and noted the pureed foods were blended only with flavorless thickener.
Failure to Follow Antibiotic Stewardship Criteria: A resident with ESRD, dialysis dependence, and cellulitis was given gentamicin eye drops for an ear infection even though the infection prevention review found the resident did not meet McGeer's criteria. The IPN did not notify the physician, and an RNS stated it was the licensed nurse's responsibility to inform the physician when an antibiotic is prescribed without infection criteria being met.
Failure to Educate and Offer COVID-19 Vaccine to Staff: The facility did not document that two physicians were educated on or offered the COVID-19 vaccine for the respiratory season. Record review with the IPN showed no evidence that either physician received vaccine education or an offer of vaccination, even though both actively cared for residents. Facility policy required COVID-19 vaccine education, offering the vaccine to all staff, and maintaining staff vaccination documentation in personnel files.
A facility failed to implement a comprehensive water management plan, did not monitor or document all required control measures for water quality, and did not review or update infection control policies as required. A resident with Legionella pneumonia was admitted without staff identifying or reporting the infection to public health authorities in a timely manner, due to incomplete review of medical records and lack of communication. The facility's policies for annual review and reporting were not followed, and there was no evidence of policy updates or quality assurance documentation.
The facility failed to maintain Jello items at the required temperature of 41 degrees Fahrenheit or lower. The Dietary Supervisor (DS) measured the temperature of Jello items in the kitchen, finding them at 54 degrees and 48 degrees, which is above the required temperature for cold food. The DS acknowledged that the Jello should be kept at 41 degrees or lower to prevent spoilage and maintain taste.
The QAA Committee failed to identify and address systemic issues affecting all residents, including medication administration, dialysis assessments, and food safety. The Administrator admitted these issues were not identified by the committee, despite the facility's policy requiring the QAA to address care and quality issues.
A facility failed to document a resident's pain level before removing Percocet from inventory and did not record the resident's refusal of the medication. The controlled drug record showed doses marked as wasted without proper documentation. Staff interviews revealed that the process for administering PRN pain medication was not followed, and non-pharmacological interventions were not documented as required.
A resident with Huntington's Disease and severe cognitive impairment was not properly monitored while using an abdominal binder to prevent g-tube removal. The facility failed to document assessments, and staff acknowledged inadequate monitoring. Policies on restraint reduction and reassessment were not followed, potentially leading to unnecessary restraint.
A facility failed to review and update a resident's care plans quarterly, as required. The resident, with conditions including acute respiratory failure and dementia, had care plans due for review but not updated by February 2025. Interviews with the MDS Coordinator and DON confirmed the oversight, which violated the facility's policy for quarterly care plan reviews.
A facility failed to document a resident's pain level before administering Percocet, leading to potential medication errors. Additionally, another resident with a penile erosion missed a urology appointment due to transportation issues, and the physician was not notified, delaying necessary care. These actions did not meet professional standards and increased the risk of infection.
A facility failed to change a resident's foley catheter drainage bag as ordered, despite the resident's diagnoses of acute kidney failure and acute cystitis. The order to change the bag every seven days was not followed on multiple occasions, as confirmed by the RN and DON. This deficiency in catheter care was identified through interviews and record reviews.
A facility failed to adhere to professional standards in oxygen administration for three residents. One resident lacked necessary signage for oxygen use, while two others had undated nasal cannulas, increasing infection risk. Additionally, one resident's oxygen use was not documented in the MAR, compromising care. The DON acknowledged these deficiencies, which contravened facility policies.
The facility failed to provide adequate dialysis care for three residents. A resident did not receive pre-dialysis assessments, and their dialysis form was incomplete. Another resident lacked emergency equipment at the bedside for potential bleeding from an AV shunt. A third resident did not receive post-dialysis assessments, with missing dialysis forms. The facility's dialysis care policy was not followed, leading to these deficiencies.
A facility failed to maintain an up-to-date competency checklist for an LVN, as the checklist was 11 months overdue. This oversight was identified during a review and interview with the DSD, who emphasized the importance of current competencies for ensuring proper nursing care. The DON confirmed that competencies are conducted annually and as needed, in line with the facility's policy to ensure staff competencies for resident safety and care.
The facility's medication administration policy was outdated, referring to paper MARs instead of the current eMAR system. The DON confirmed the need for policy updates to reflect the electronic documentation method, as the existing policy could lead to inaccurate records and potential drug loss or diversion.
Two residents received blood pressure medications despite their blood pressure readings being below the prescribed parameters. One resident with essential hypertension was given Metoprolol when their systolic blood pressure was below 110 mmHg, and another resident with end-stage renal disease received hydralazine hydrochloride under similar conditions. These actions were contrary to physician orders and acknowledged by facility staff.
The facility failed to properly store and label medications, with active medications found in a cabinet for discontinued drugs and multiple-dose containers lacking open dates. This led to potential medication errors, as observed by an LVN who confirmed the improper storage of 17 blister packs and outdated inhalation solutions.
A resident with multiple health conditions experienced a delay in laboratory test completion, with tests ordered on February 1 not drawn until February 18. The facility's policy requires timely completion and communication of lab results, which was not adhered to, potentially impacting the resident's care.
The facility failed to label and date food items, remove expired items, and test sanitizing solutions and dish machine temperatures. Unlabeled and expired items were found, and sanitizing solutions were not tested, posing contamination risks. The facility's policies were not followed, leading to potential resident safety issues.
A resident with end-stage renal disease had incomplete and falsified Dialysis Communication Records due to the failure of licensed nursing staff to document post-dialysis assessments accurately. An LVN admitted to falsifying records on days he was not working, leading to inaccurate medical records. The facility's policy requires timely and accurate documentation, which was not followed.
The facility failed to maintain proper infection control practices, including keeping a resident's foley catheter tubing off the floor, ensuring staff used appropriate PPE for a resident on Enhanced Barrier Precautions, and conducting an annual Legionella Risk Assessment. Staff interviews confirmed the importance of these practices, but deficiencies were observed, such as a lack of hand hygiene and inaccessible PPE.
A facility failed to offer and monitor flu and pneumococcal vaccinations for a resident with cognitive impairments and multiple health conditions. The resident's immunization status was not documented, and the vaccination tracking spreadsheet was outdated, leading to incomplete medical records.
A resident with severe cognitive impairment and multiple diagnoses was not included in their initial IDT care conference, violating their rights to participate in their care plan. The facility's policy requires resident involvement, but the resident was absent without documentation of refusal.
A facility failed to create a comprehensive care plan for a resident using anticoagulant medication. The resident, with acute respiratory failure and atrial fibrillation, required Apixaban via a gastrostomy tube but lacked a care plan to guide its use. Staff confirmed the absence of this essential plan, which is required by facility policy to ensure quality care.
The facility failed to document the COVID-19 vaccination status of all employees, including physicians and consultants, as required by their policy. The IPN was unaware of the immunization status of these individuals, and the DON emphasized the necessity of knowing the vaccination status of all staff in contact with residents. This oversight potentially endangered staff and residents by increasing the risk of COVID-19 infection.
The facility failed to meet the requirement of 80 square feet per resident in 20 out of 29 rooms, with measurements ranging from 69.16 to 79.6 square feet per resident. Despite this, residents reported no issues with room size, and staff were able to provide adequate care. The administrator acknowledged the deficiency but noted resident satisfaction and staff capability.
Dirty Ice Machine Used for Resident Ice Service
Penalty
Summary
The facility failed to ensure that its ice machine, which was used to produce ice for resident distribution and consumption, was clean for safe and sanitary operation. During a concurrent observation and interview in the kitchen with the Maintenance Director, the ice machine’s internal components were inspected and white-colored matter was observed in the ice cube product chute, black-colored matter was present on the interior wall of the machine housing, and large surface areas of white-colored matter were present on the submerged surface of the feed water collection basin used to produce ice. During a later concurrent observation and interview, the Dietary Supervisor also observed the ice machine and stated that it was not clean and that residents can get sick and have diarrhea and other illnesses from dirty ice. A review of the facility’s diet information showed that 50 residents out of 55 listed were subject to receiving and consuming ice from the machine, and the Dietary Supervisor stated that 55 of 56 residents were subject to ingesting ice from the facility’s ice machine. The facility’s policy stated that the ice machine shall be cleaned to maintain sanitary conditions and prevent food contamination and the growth of disease-producing organisms and toxins, and the manufacturer’s manual stated that the ice machine and storage bin must be kept in a sanitary condition.
Failure to Implement QAPI Corrective Action Planning
Penalty
Summary
The facility failed to follow its QAPI process by not developing documented corrective action plans or performance improvement activities to address identified quality topics. During a concurrent interview and record review with the Administrator, the facility's QAPI binder was reviewed and the Administrator stated that falls, pressure injuries, and legionella water management were active QAPI topics. The Administrator also stated that falls and pressure injury interventions and corrective actions were implemented on an individual level, but did not provide documented plans or corrective actions that the facility had implemented for these QAPI topics. During the review of the facility's policy and procedure titled Quality Assurance Performance Improvement Plan & Committee (QAPI), the Administrator stated the policy indicated the QAPI plan would identify and use data to monitor performance, establish goals and thresholds, utilize resident and staff input, identify and prioritize problems and opportunities for improvement, analyze underlying causes of systemic problems and adverse events, and develop corrective action plans or performance improvement activities. The Administrator stated not following the QAPI policy could result in unsafe practices. The policy also indicated that at the beginning of each performance improvement project, goals, scope, timing, milestones, team roles, and responsibilities would be developed and clearly established by the QAA committee and given to the team carrying out the performance.
Call light not within reach for a resident with severe sensory impairments
Penalty
Summary
The facility failed to ensure the call light device was within reach for Resident 53. During an observation in the resident’s room, the call light was wrapped around the plug on the wall while the resident’s right hand groped for something constantly. Resident 53’s admission record showed diagnoses including legal blindness, deafness, and congenital Rubella Syndrome, and the H&P dated 12/13/2025 indicated the resident had no capacity to understand and make decisions. Resident 53’s MDS dated 3/20/2026 showed the resident required dependent assistance from two or more staff for shower/bath, transfer, bed mobility, dressing, and hygiene, and maximal assistance from one staff for eating and oral hygiene. The care plan for risk for fall and injury related to poor safety awareness included an intervention to keep the call light within reach and answer promptly. During interviews, an LVN and an RNS stated the call light should always be accessible and within the resident’s reach, and the facility’s policy stated staff should make sure the call light is within easy reach when the resident is in bed, wheelchair, or chair.
Failure to Offer Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents or their responsible parties were given the opportunity to formulate an advance directive for three sampled residents. Resident 6 was admitted and readmitted with diagnoses including acute respiratory failure with hypoxia, chronic kidney disease on dialysis, and dementia. The H&P stated Resident 6 did not have the capacity to understand and make decisions, and the MDS showed severe cognitive impairment with dependence or need for assistance with multiple activities of daily living. During record review, the Social Services Director reviewed Resident 6’s psychosocial assessment, POLST, and advance directive form and stated the resident did not have an advance directive, and the blank form did not show that the resident or responsible party had been offered or educated about the right to formulate one. Resident 25 was admitted and readmitted with diagnoses including acute respiratory failure with hypoxia, UTI, and osteomyelitis of the right ankle and foot. The H&P stated Resident 25 did not have the capacity to understand and make decisions, while the MDS showed intact cognition but also need for assistance with eating, oral hygiene, dressing, toileting hygiene, bathing, and lower body dressing. During review with the Social Services Director, Resident 25’s advance directive form was blank, and the director stated the advance directive acknowledgement should be completed on every readmission. Resident 1 was admitted and readmitted with diagnoses including cerebral palsy, pneumonia, and malignant neoplasm of the left breast and bone. The H&P stated Resident 1 did not have the capacity to understand and make decisions, and the MDS showed severe cognitive impairment with dependence for eating, oral hygiene, toileting hygiene, bathing, and upper and lower body dressing. During review with the Social Services Director, Resident 1’s POLST indicated no advance directive, and the advance directive form did not show that the resident or responsible party was offered or educated about the right to formulate an advance directive. The facility policy stated that prior to or upon admission, residents are to be provided written information concerning the right to accept or refuse treatment and the right to prepare an advance directive.
Incomplete SNF ABN forms were not explained in a way two residents understood
Penalty
Summary
The facility failed to ensure that 2 of 3 sampled residents, Resident 8 and Resident 42, were provided the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) in a manner they understood. Resident 8 was admitted and later readmitted with diagnoses including polyneuropathy, cellulitis of the right lower limb, and COPD. The resident’s H&P indicated capacity to understand and make decisions, and the MDS showed intact cognition. During interview, Resident 8 stated they did not understand the share of cost the facility was charging monthly. Review of the NOMNC and SNF ABN with the Business Office Manager showed the SNF ABN was signed, but it did not indicate which option Resident 8 chose regarding continued skilled services or who would pay the bill, and the BOM stated Resident 8 did not select an option on the form. Resident 42 was admitted and later readmitted with diagnoses including polyneuropathy, heart failure, and COPD. The resident’s H&P indicated capacity to understand and make decisions, and the MDS showed intact cognition with varying levels of assistance needed for activities of daily living. Review of the NOMNC and SNF ABN with the Business Office Manager showed the SNF ABN was signed, but it did not indicate which option Resident 42 chose regarding continued skilled services or who would pay the bill, and the BOM stated Resident 42 did not select an option on the form. Resident 42 stated they remembered receiving the SNF ABN but did not understand why the facility was taking so much money. The BOM stated it was their responsibility to explain the SNF ABN, ensure the resident understood it, and ensure the resident selected an option. The facility policy stated it was the facility’s responsibility to ensure forms were completed per Medicare guidelines and given to the resident or representative timely.
Failure to Identify and Monitor Abdominal Binder as a Restraint
Penalty
Summary
The facility failed to identify, assess, monitor, and document the use of an abdominal binder for one resident who had a G-tube and a history of pulling at essential devices. During observation, the resident was seen with a splint on the right hand and right arm and an abdominal binder in place. The resident had difficulty moving the right arm and both legs, could move the left arm with weakness, and had diagnoses including quadriplegia, cerebral infarction, pathological fracture, and dementia. The resident’s H&P stated the resident had no capacity to understand and make decisions. The resident’s OSR showed an order to place the abdominal binder at all times to prevent pulling out the G-tube. During interview, the RNS stated there was no order to monitor and assess skin under the abdominal binder every two hours and no documentation regarding monitoring and assessment of skin integrity and abdominal binder use. The RNS stated the resident was at risk for skin breakdown and compromised circulation due to prolonged abdominal binder use. The MDS section P indicated no trunk or limb restraints were in use, and the MDSC stated she did not realize the abdominal binder could be considered a restraint because it prevented access to the resident’s body and the resident could not remove it independently. The DSD reviewed an undated informed consent for the abdominal binder and stated the verbal consent by telephone had no documented date and was incomplete and invalid. The DSD stated staff failed to identify the abdominal binder as a restraint and failed to assess, monitor, and document its use. The facility policy defined restraints as devices the resident cannot easily remove and required assessment, informed consent, a physician’s order, and a plan of care before use.
Inaccurate MDS Coding for Abdominal Binder Restraint
Penalty
Summary
Resident 7 was observed with an abdominal binder in place during a room observation, and the resident had difficulty moving the right arm and both legs, with the left arm movable but weak. The resident’s record showed an admission history including quadriplegia, cerebral infarction, pathological fracture, and dementia, and the H&P stated the resident had no capacity to understand and make decisions. The MDS also documented dependent assistance from two or more staff for dressing, hygiene, bed mobility, and transfer, along with impairment on both sides of the upper and lower extremities. During record review, the facility’s OSR directed staff to place an abdominal binder at all times to prevent pulling out of the G-tube. However, the MDS Section P dated 1/26/2026 indicated the resident did not have any trunk or limb restraints in use. In interview, the MDSC stated she did not realize the abdominal binder could be considered a restraint because it prevented the resident from access to the body and the resident could not remove it independently. The DSD stated that MDS assessments should be coded correctly because inaccurate coding affects the resident’s overall care and treatment, and the facility policy stated the RAI process is used for accurate assessment of each resident’s functional capacity and health status.
Incomplete Antibiotic Care Planning and Failure to Follow Abdominal Binder Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for gentamicin therapy for a resident with ESRD, dependence on renal dialysis, and cellulitis. The resident was admitted and later readmitted to the facility, and the H&P dated 3/19/2026 indicated the resident had capacity to understand and make decisions. The MDS dated 3/25/2026 showed moderate cognitive impairment and dependence or need for assistance with multiple activities of daily living. The resident had an order for gentamicin sulfate ophthalmic solution in the left ear twice daily for an ear infection for 7 days starting 4/9/2026, and the April 2026 MAR showed the medication was administered as scheduled from 4/9/2026 through 4/16/2026. During interview and record review, the Infection Prevention Nurse stated the resident did not have a care plan for antibiotic therapy related to gentamicin. The IPN stated a care plan for gentamicin should be initiated so the facility would know what to monitor and the plan of care. The IPN also stated that if a care plan for antibiotics is not initiated, the resident may be at risk for not receiving appropriate care or may not meet goals. RNS 1 stated care plans are initiated on admission, quarterly, annually, and as needed for significant changes or changes of condition, and stated that without a care plan for gentamicin staff may not know what to monitor, the type of antibiotic, the plan, or when to evaluate whether it is effective. The facility also failed to implement the comprehensive person-centered care plan for abdominal binder use for a resident with quadriplegia, cerebral infarction, pathological fracture, and dementia. The resident had no capacity to understand and make decisions and required dependent assistance from two or more staff for dressing, hygiene, bed mobility, and transfer. An abdominal binder was observed on the resident in the room, and the OSR indicated an order to place the abdominal binder at all times to prevent pulling out the G-tube, which had been ordered on 10/30/2025. RNS 1 stated there was no order to monitor and assess skin under the abdominal binder every two hours and no documentation regarding monitoring and assessment of skin integrity and abdominal binder use. The resident’s care plan, initiated on 10/28/2025, stated the resident required an abdominal binder secondary to pulling out the feeding tube and included goals and interventions to assess use of the binder, assess skin underneath it routinely, and assess for possible discontinuance. The MDSC stated the interventions reflected IDT recommendations and should be implemented to prevent unintended skin breakdown and injury. The DSD stated the care plan is a specific plan of care that should be implemented as written, and that staff should have followed the interventions to assess, monitor, and document abdominal binder use to prevent skin injuries and complications such as compromised circulation and entrapment.
Failure to Provide Communication Support for a Spanish-Speaking Resident
Penalty
Summary
The facility failed to ensure Resident 58 was provided with a communication board and language translating service in a language the resident could understand. Resident 58 was admitted with diagnoses including malignant neoplasm of breast, chronic pain, and history of falling, and the H&P stated the resident had no capacity to make decisions. The MDS showed the resident required varying levels of assistance with bed mobility, showering, dressing, toileting hygiene, personal hygiene, oral hygiene, and eating. The care plan identified Resident 58 as at risk for impaired communication skills and stated that a communication device would be used to anticipate and meet needs. During observation, Resident 58 attempted to explain something in Spanish, but CNA 2 stated she could not understand and no communication board was at the bedside. CNA 2 stated she did not speak Spanish, could not find anyone on the floor who could speak Spanish, and had never used the language translating service. Later, PS 1 was brought in to translate and Resident 58 smiled and thanked her, while PS 1 stated the resident sometimes had difficulty getting needs met when no Spanish-speaking staff were available and that she might not help with medical-related needs. The SSD stated the facility had a contract for language translating service via iPad but she had never used it and did not know how to access it, and the DSD stated the communication board should always be available and the translating service instructions should be available to staff. The facility policy stated it was the facility's policy to meet the needs of residents who present with communication barriers.
Improperly Secured Medications in Crash Cart
Penalty
Summary
The facility failed to properly store medications safely in a locked crash cart located by Nursing Station 1. During observation, the crash cart was unattended with a key inserted in the lock, and the top drawer contained a box of glucose gels and normal saline syringes. An LVN stated the key was always left in the lock so it would be available for emergencies. During interview, an RNS stated glucose gels are medications used for emergencies such as hypoglycemia and that normal saline syringes are medications that require an order for use. The RNS also stated only licensed staff should have keys to access medications and that glucose gels and normal saline syringes should not be freely accessible. The facility policy titled Medication Storage in the Facility stated only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications, and medication rooms, carts, and medication supplies are to be locked or attended by persons with authorized access.
Food Served Bland and at Improper Temperature
Penalty
Summary
The facility failed to ensure food served was palatable and/or at the preferred temperature for three sampled residents. Resident 19 had diagnoses including DM, dysphagia, and hypertension, and his records showed he was on a regular texture, consistent carbohydrate, no added salt, thin liquid diet. He told staff that food was served cold and without seasoning, that breakfast was usually the worst meal, and that vegetables were bland and flavorless. During observation, he received breakfast with Southwestern casserole, wheat toast, oatmeal, fruit punch juice, and milk, and he stated that his oatmeal was lukewarm and tasteless and that the casserole was bland. He refused to eat and asked for a ham and cheese sandwich. Resident 60 had diagnoses including cellulitis of the right arm, hypertension, and acute kidney failure, and his records showed he was on a regular texture with thin liquids. He stated that hot food had frequently been served lukewarm or cold and that steamed vegetables looked unappetizing and bland. He reported having to ask staff to reheat food, but said microwaving changed the texture in a very unpleasant way. During another interview, he stated he was upset about lunch because steamed carrots were not seasoned at all, looked mushy, and caused him to lose his appetite. He also stated that he skipped meals sometimes. Resident 53 had diagnoses including legal blindness, deafness, Congenital Rubella Syndrome, and dysphagia, and his records showed he was on a pureed, consistent carbohydrate, honey thick liquid, double portion diet. During observation, he was assisted with feeding and received pureed barbeque chicken, carrots, wheat roll, and potato salad. He tasted the pureed carrots and wheat roll and then shut his mouth tightly when offered more food. The CNA stated that he did not like the pureed carrots and wheat roll. The Dietary Supervisor later tasted the regular and pureed carrots and pureed wheat roll and agreed they were bland, stating they should have used salt substitute and that the pureed items were blended only with flavorless thickener. The facility’s recipe for pureed breads and vegetables called for adding warm liquid, food thickener if needed, and adjusting seasoning as needed after tasting, and the RD stated food should be palatable and appetizing for all residents regardless of diet.
Failure to Follow Antibiotic Stewardship Criteria
Penalty
Summary
The facility failed to follow its antibiotic stewardship policy for one resident when the infection prevention nurse did not inform the physician that the resident did not meet McGeer's criteria for an infection before gentamicin sulfate ophthalmic solution was administered. The resident was admitted and later readmitted with diagnoses including ESRD, dependence on renal dialysis, and cellulitis. The resident's H&P dated 3/19/2026 indicated the resident had the capacity to understand and make decisions, while the MDS dated 3/25/2026 indicated moderate cognitive impairment and varying levels of assistance needed for eating, oral hygiene, dressing, toileting hygiene, and bathing. The resident's order summary showed an order dated 4/9/2026 for gentamicin sulfate ophthalmic solution 0.3% two drops in the left ear twice daily for ear infection for 7 days, and the April 2026 MAR showed the medication was administered as scheduled from 4/9/2026 through 4/16/2026. During interview and record review, the infection prevention nurse reviewed the surveillance log, surveillance data collection form, and nursing notes and stated the resident did not meet McGeer's criteria, but the nurse did not notify the physician because they did not feel it was right to stop something if the resident needed it. A registered nurse supervisor stated it was the licensed nurse's responsibility to inform the physician when a resident is prescribed an antibiotic and does not meet criteria for an infection.
Failure to Educate and Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to educate and offer the COVID-19 vaccine for the 2025-2026 respiratory season to two of five sampled staff members, Physician 1 and Physician 2, and failed to document their vaccination status. During a concurrent interview and record review with the Infection Prevention Nurse, the staff vaccination records showed no documentation that either physician was offered the COVID-19 vaccination or educated on the risks and benefits of receiving it. The Infection Prevention Nurse stated that both physicians actively cared for current residents. During a later interview, Registered Nurse Supervisor 1 stated it was important to offer the COVID-19 vaccine and educate all staff to prevent spread of the virus to residents, and stated the COVID-19 consent form is proof that the facility encouraged and educated staff about the vaccine. The facility policy stated that COVID-19 vaccinations will be offered to all staff and residents per CDC and/or FDA guidelines, that all staff and residents/representatives will be educated on the vaccine in a manner they can understand, and that documentation of vaccination status will be maintained in personnel files for staff.
Failure to Implement Water Management and Infection Control Measures for Legionella
Penalty
Summary
The facility failed to implement effective infection control measures related to its water management program and reporting of Legionella infection. The maintenance supervisor was unable to provide evidence of a comprehensive water management plan beyond daily water temperature logs, and there was no documentation of monitoring or control measures for water quality or disinfectant levels. The infection preventionist nurse confirmed that the facility did not have a customized water management policy and was not monitoring all necessary control measures and limits as recommended by CDC guidelines. The facility's policy required a water management program with annual review, but there was no evidence of such review or updates since 2017. A resident was admitted and later readmitted with multiple diagnoses, including pneumonia and sepsis. The resident was diagnosed with Legionella pneumonia at a general acute care hospital, but this information was not identified or acted upon by facility staff upon readmission. The registered nurse supervisor and director of nursing both acknowledged that the resident's medical records were not thoroughly reviewed, resulting in a delay in recognizing the Legionella infection. The infection preventionist nurse was only made aware of the positive Legionella result after notification from a public health nurse, rather than through internal review or communication from the hospital. The facility also failed to report the confirmed case of Legionella infection to the California Department of Public Health as an unusual occurrence within the required 24-hour timeframe. Review of facility policies indicated that such events should be reported promptly, but staff were unaware of the infection until notified by public health authorities. Additionally, there was no documentation in the facility's quality assurance and performance improvement records to show that infection control and water management policies were reviewed or updated annually, as required by facility policy.
Failure to Maintain Proper Temperature for Jello Items
Penalty
Summary
The facility failed to maintain Jello items at the required temperature of 41 degrees Fahrenheit or lower, as observed during a survey. On multiple occasions, the Dietary Supervisor (DS) measured the temperature of Jello items in the kitchen, finding them at 54 degrees and 48 degrees, which is above the required temperature for cold food. The DS acknowledged that the Jello should be kept at 41 degrees or lower to prevent spoilage and maintain taste. The facility's policy, dated 2023, states that cold food items should be placed on trays as close to serving time as possible to ensure they remain below 41 degrees.
QAA Committee Fails to Address Systemic Issues
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to identify and implement corrective actions for systemic issues affecting all 47 residents. These issues included not following medication parameters when administering medications, not assessing dialysis residents before and after their treatments, and not ensuring that the kitchen stored, prepared, and distributed food according to professional food service safety standards. During an interview, the Administrator acknowledged that these systemic issues were not identified by the QAA committee. A review of the facility's Quality Assurance Performance Improvement Plan and Committee policy, revised in December 2024, indicated that the QAA committee was responsible for identifying and addressing specific care and quality issues and implementing action plans to resolve them. However, these deficiencies placed residents at risk of not receiving the necessary quality treatment to meet their highest practicable well-being.
Failure to Document Pain Level and Medication Refusal
Penalty
Summary
The facility failed to ensure proper documentation of a resident's pain level before removing pain medication from inventory and failed to document the resident's refusal of administration. This deficiency was identified for one resident who was prescribed Percocet for moderate to severe pain. During an observation, it was noted that the medication cart contained a blister pack of Percocet for the resident, and the controlled drug record showed two doses marked as wasted without corresponding documentation of the resident's pain level or refusal of the medication on the specified dates. Interviews with facility staff revealed that the process for administering PRN pain medication was not followed, as the resident's pain level was not documented in the electronic medication administration record (eMAR) before the medication was removed. Additionally, the facility's policy required that non-pharmacological interventions be performed and documented if the pain level did not meet the criteria for medication administration, which was not done. The director of nursing confirmed that the narcotic medication should not have been accessed if the pain level did not meet the prescribed criteria.
Inadequate Monitoring of Abdominal Binder Use
Penalty
Summary
The facility failed to appropriately assess and monitor a resident during the use of an abdominal binder, which was used to prevent the resident from pulling out a gastrostomy tube. The resident, who was diagnosed with Huntington's Disease and had severely impaired cognitive skills, was dependent on all aspects of activities of daily living. The resident's care plan required the use of an abdominal binder at all times, except during ADLs, to prevent the removal of the g-tube. However, the facility did not document or monitor the use of the abdominal binder properly, as indicated by the Medication Administration Record, which showed only an 'X' instead of detailed assessments. During an observation and interview, a Licensed Vocational Nurse confirmed that the resident always wore the abdominal binder to prevent pulling out the g-tube due to uncontrollable movements. The Director of Staff Development acknowledged that the documentation was inadequate and that the abdominal binder should have been monitored more closely. The Director of Nursing stated that while the abdominal binder was necessary to protect the g-tube, it required consent and monitoring for skin integrity and should be released during ADLs to prevent skin breakdown. The facility's policies and procedures on restraint assessments and physical restraints indicated that restraints should be gradually reduced and regularly reassessed for necessity. However, the facility did not follow these guidelines, as the need for the abdominal binder was not periodically reevaluated, and there was no documentation of attempts to minimize or eliminate its use. This lack of proper assessment and monitoring had the potential to place the resident under unnecessary restraint.
Failure to Review and Update Resident Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that a resident's care plans were reviewed and updated on a quarterly basis, as required. The resident, who was admitted with diagnoses including acute respiratory failure, type 2 diabetes, hypertension, and dementia, had care plans created on a specific date. These care plans, covering areas such as cognitive loss, communication, and cardiac circulation, were due for review in November 2024 but had not been reviewed by February 2025. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the care plans should have been reviewed and reevaluated since November 2024. The facility's policy requires that comprehensive, person-centered care plans be reviewed and revised at least quarterly to reflect any changes in the resident's condition and ensure that services provided are consistent with the resident's written plan.
Documentation and Consultation Failures in Pain Management and Urology Care
Penalty
Summary
The facility failed to ensure proper documentation and administration of pain medication for Resident 43. During an observation, it was noted that the nurse did not document the resident's pain level before removing Percocet from the inventory, nor was there documentation of the resident's refusal of the medication on two occasions. The facility's process requires that the resident's pain level be documented in the electronic medication administration record (eMAR) before preparing the medication. However, the eMAR did not reflect any pain episode or refusal, and the pain levels recorded did not meet the criteria for administering the medication. Additionally, non-pharmacological interventions were not documented as performed after the pain assessment. The facility also failed to ensure that Resident 48 received timely urology consultation and services to meet professional standards of practice. Resident 48, who was admitted with a penile erosion and other conditions, had a scheduled urology appointment that was missed due to transportation issues. The appointment was rescheduled, but the physician was not notified of the missed appointment. The resident's care plan identified a high risk for infection, and the Director of Nursing stated that it was unacceptable to delay the urologist's consult without notifying the physician, as this could lead to infections. The facility's policies and procedures require communication with the physician regarding negative responses to treatment or changes in the resident's condition. However, the failure to notify the physician of the missed appointment and the lack of timely urology consultation did not meet the standard of practice. This oversight had the potential to compromise the resident's care and increase the risk of infection due to the existing wound and other health conditions.
Failure to Change Foley Catheter Bag as Ordered
Penalty
Summary
The facility failed to ensure that a resident's foley catheter drainage bag was changed as ordered, which is a deficiency in providing appropriate catheter care. The resident, who was readmitted to the facility with acute kidney failure and acute cystitis, had an order to change the foley catheter bag every seven days. However, the task was not completed on the specified dates of 1/9/2025, 1/16/2025, and 1/23/2025, as indicated in the Treatment Administration Record (TAR). The Registered Nurse (RN) acknowledged that the orders were not followed and should have been clarified if deemed inappropriate. The Director of Nursing (DON) confirmed that physician orders must always be followed, and the facility's policy on indwelling catheter care, revised in 3/2021, mandates that catheter care be provided as ordered. The failure to adhere to the physician's orders for catheter care had the potential to result in complications that could negatively affect the resident's wellbeing. This deficiency was identified through interviews and record reviews conducted by the surveyors.
Deficiencies in Oxygen Administration and Documentation
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for three residents receiving supplemental oxygen. Resident 5, who was readmitted with acute respiratory failure and asthma, was observed using oxygen without any visible signage indicating oxygen use, which is necessary for safety reasons. The Licensed Vocational Nurse confirmed the absence of signage, and the Director of Nursing acknowledged the need for such signage to prevent hazardous practices. Resident 30, diagnosed with chronic obstructive pulmonary disease, was observed using a nasal cannula that was not labeled with a date, which is essential for infection control. The Registered Nurse confirmed the lack of dating on the nasal cannula and emphasized the importance of dating to prevent infections. The Director of Nursing also noted that Resident 30 was at high risk for infections due to age and medical conditions, and the absence of dating could increase this risk. Resident 49, with pulmonary hypertension and hypoxia, was similarly observed using a nasal cannula without a date, posing a risk of infection. Additionally, the Medication Administration Record for Resident 49 did not document the use of oxygen, which is necessary for proper care. The Director of Nursing confirmed the omission in documentation and the risk of infection due to the resident's comorbidities and immunodeficiency. The facility's policy requires documentation of oxygen administration and regular replacement of nasal cannulas, which was not adhered to in these cases.
Inadequate Dialysis Care and Monitoring for Residents
Penalty
Summary
The facility failed to provide adequate dialysis care and services for three residents requiring hemodialysis. Resident 113, who was admitted with end-stage renal disease and had severely impaired cognition, did not receive a pre-dialysis assessment before being sent to the dialysis center. The dialysis form for Resident 113 was missing from the medical records, and the pre and post-assessment sections were not completed, indicating a lack of continuity of care. Resident 17, who had diagnoses including end-stage renal disease and type 2 diabetes mellitus, did not have the necessary emergency equipment at the bedside to manage potential bleeding from an arteriovenous shunt. A Licensed Vocational Nurse (LVN) noted the absence of an emergency kit and expressed concern about the potential for uncontrolled bleeding, which could lead to severe outcomes. The Director of Nursing (DON) emphasized the importance of having an emergency kit readily available for dialysis residents. Resident 27, admitted with end-stage renal disease and other conditions, also did not receive a post-dialysis assessment upon returning from the dialysis center. The dialysis forms for several dates were missing, and the post-assessment sections were not completed. LVNs and the DON highlighted the importance of post-dialysis monitoring to ensure residents' stability and the absence of complications. The facility's policy and procedure for dialysis care, which includes pre and post-dialysis checklists, was not followed, contributing to these deficiencies.
Outdated Competency Checklist for LVN
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 9) had the necessary competencies and skills to care for residents, as evidenced by the outdated SNF Licensed Nurse Orientation Annual Competency checklist. LVN 9 was hired on August 22, 2023, and completed the competency checklist on September 18, 2023, with an expiration date of March 31, 2024. However, as of February 20, 2025, the checklist was 11 months past due. This lapse in maintaining up-to-date competencies was identified during a record review and interview with the Director of Staff Development (DSD), who acknowledged the importance of current competencies to ensure that nurses perform their duties correctly and adhere to facility policies. The Director of Nursing (DON) confirmed that competencies are conducted annually and as needed for all staff to ensure proper resident care. The facility's policy, dated January 2017, mandates periodic performance reviews to verify staff competencies, which are crucial for resident safety and effective care delivery. The failure to update LVN 9's competency checklist had the potential to result in residents not receiving appropriate nursing services and care, which could lead to injury.
Outdated Medication Administration Policy
Penalty
Summary
The facility failed to update its policy regarding medication administration documentation to align with its current practice of using electronic medication administration records (eMAR) instead of paper MARs. The existing policy, dated October 2017, still referred to the use of paper MARs, which were no longer in use. During an interview, the Director of Nursing (DON) confirmed that the facility had transitioned to eMARs and that the current practice involved nurses initiating a text box in the eMAR for documentation. The DON acknowledged that the policy needed to be updated to reflect this change. This oversight had the potential to result in inaccurate records, drug loss, and/or diversion.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to prescribed medication administration protocols for two residents, leading to potential health risks. Resident 112, who was admitted with essential hypertension, had a physician's order to hold Metoprolol if the systolic blood pressure was below 110 mmHg. Despite this, the medication was administered on two occasions when the resident's blood pressure readings were 100/74 mmHg and 106/68 mmHg, respectively. This oversight was confirmed during an interview with RN1, who acknowledged that the medication should not have been given under these conditions. Similarly, Resident 27, diagnosed with end-stage renal disease and essential hypertension, was prescribed hydralazine hydrochloride with instructions to hold the medication if the systolic blood pressure was below 110 mmHg. However, the medication was administered when the resident's blood pressure was recorded at 106/64 mmHg and 105/63 mmHg on separate occasions. The Director of Staff Development confirmed that the medication was given contrary to the physician's order, which could lead to further lowering of the resident's blood pressure. The Director of Nursing also acknowledged that not following the blood pressure parameters could result in hypotension for the residents.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that active medications for current residents were not stored in a cabinet labeled for discontinued medicines. During an observation in the medication room, a licensed vocational nurse (LVN 3) confirmed that 17 multiple-dose blister pill packs, which were active medications for 8 residents, were incorrectly stored in a cabinet meant for discontinued or discharged medications. The facility's policy indicated that newly delivered medications should be stored in the medication carts, but this was not followed, leading to the potential for medication errors. Additionally, the facility did not ensure that multiple-dose medication containers had an open date and that outdated medications were not stored in the medication cart. During an observation, it was found that two boxes of ipratropium bromide/albuterol sulfate inhalation solutions were improperly stored, with one box lacking an open date and the other being opened for more than two weeks, contrary to the manufacturer's instructions. The facility's policy required that medications be stored safely and outdated medications be immediately removed, which was not adhered to in this instance.
Delay in Laboratory Test Completion for Resident
Penalty
Summary
The facility failed to ensure timely completion of laboratory tests for a resident, resulting in a delay of care. The resident, who was admitted with acute respiratory failure, type 2 diabetes, hypertension, and dementia, had an order for several lab tests including a basic metabolic profile, prealbumin, Glycohemoglobin (Hb A1C), complete blood count, and thyroid stimulating hormone. These tests were ordered on February 1, 2025, but were not drawn until February 18, 2025, a delay of seventeen days. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the lab tests should have been completed sooner and that lab orders need to be completed as ordered with results relayed to the ordering physician promptly. The facility's policy indicated that laboratory reports should be performed as prescribed by the physician and filed in the resident's medical record, with abnormal results promptly communicated to the physician. The delay in completing the lab tests had the potential to result in a continued undiagnosed problem that could be harmful to the resident.
Deficiencies in Food Labeling, Expiration Management, and Sanitization Testing
Penalty
Summary
The facility failed to properly label and date food items, remove expired items, and test and document the concentration of sanitizing solutions and dish machine temperatures. During an observation, several food items, including an opened bottle of 'Thick and Easy', chicken noodle soup, zucchinis, celery, lettuce, tomatoes, and cookie dough, were found without proper labeling or date marking. The Dietary Supervisor (DS) could not confirm the opening or delivery dates for these items. Additionally, expired items such as Diabetisource AC and two bags of bread were found in the kitchen, with the DS unable to confirm the dates represented on the labels. The facility also failed to test and document the concentration of sanitizing solutions and dish machine temperatures prior to use. A red sanitary bucket was found with an expired test strip, and logs indicated that kitchen staff did not test or document the dish machine temperatures or sanitizing solutions before use. Interviews with the Director of Nursing (DON) and the DS confirmed that these practices could lead to contamination and foodborne illness. The facility's policies and procedures require proper labeling, dating, and testing, but these were not followed, leading to potential risks for residents.
Inaccurate and Falsified Dialysis Records for a Resident
Penalty
Summary
The licensed nursing staff at the facility failed to maintain and complete accurate medical records for a resident, identified as Resident 27, who was undergoing dialysis treatment. The deficiency involved the incomplete documentation of the Dialysis Communication Record (DCR) for specific dates, which were left blank, indicating that the necessary post-dialysis assessments were not conducted. Additionally, a Licensed Vocational Nurse (LVN 8) falsified the DCR by documenting assessments on days he was not working, thereby creating inaccurate records of the resident's condition. Resident 27 was admitted with diagnoses including end-stage renal disease, hypertension, and cardiomegaly, and required substantial assistance with daily activities. The Director of Staff Development confirmed that the post-dialysis documentation was not completed on the specified dates, and LVN 8 admitted to falsifying records by filling in the DCR on days he was not present. The Director of Nursing emphasized the importance of accurate and timely documentation, as per the facility's policy, which was not adhered to in this case.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as evidenced by several deficiencies observed during the survey. Resident 7's foley catheter tubing was found lying on the floor, contrary to the care plan instructions that required the tubing to be kept off the floor to prevent infection. Licensed Vocational Nurse 4 acknowledged the issue, stating that it is the nurses' responsibility to ensure the catheter is not dragging on the floor, as this can lead to breakage and potential infection spread. Interviews with other staff, including LVN 2 and the Director of Nursing, confirmed the importance of keeping the catheter tubing off the floor to prevent infection. Another deficiency was observed with Resident 15, who was on Enhanced Barrier Precautions due to having a g-tube. LVN 3 failed to perform hand hygiene before entering the resident's room and did not wear the appropriate PPE, such as a gown, when observing the g-tube. LVN 3 admitted that PPE was not easily accessible, which contributed to the oversight. The Director of Staff Development and the Director of Nursing emphasized the importance of hand hygiene and wearing gowns for infection control, especially for residents with devices like g-tubes or foley catheters. Additionally, the facility did not conduct an annual Legionella Risk Assessment for 2024, as required by their policy. The Administrator confirmed the absence of the assessment, and the Director of Nursing highlighted the importance of Legionella prevention due to the vulnerability of the elderly population. The facility's policies and procedures for indwelling catheter care, enhanced standard precautions, hand hygiene, and Legionella prevention were reviewed, revealing that the practices observed did not align with the established guidelines.
Failure to Monitor and Document Resident Vaccination Status
Penalty
Summary
The facility failed to offer and monitor the immunization status for influenza and pneumococcal vaccinations for one of the sampled residents, identified as Resident 9. Upon review of Resident 9's admission records, it was noted that the resident was admitted with diagnoses including gastrostomy, cerebral palsy, and asthma. The resident's cognitive skills were moderately impaired, and they were dependent on all aspects of activities of daily living. A review of the immunization history report indicated that Resident 9 had no record of receiving the flu or pneumococcal vaccines. Interviews with the Infection Preventionist Nurse (IPN) and the Director of Nursing (DON) revealed that the facility's procedures for offering and documenting vaccinations were not followed. The IPN admitted that the vaccination tracking spreadsheet was not up to date and did not include Resident 9. The facility's policies required that residents be evaluated for vaccination status upon admission and that education regarding the benefits and potential side effects of immunizations be provided. However, there was no documentation in Resident 9's clinical record to indicate that these steps were taken, resulting in incomplete medical records for the resident.
Resident Excluded from Care Plan Meeting
Penalty
Summary
The facility failed to involve a resident in the development and implementation of their person-centered plan of care. Specifically, Resident 26, who was admitted with diagnoses including metabolic encephalopathy, type 2 diabetes, and muscle weakness, was not included in their initial Interdisciplinary Team (IDT) care conference. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependency on staff for all activities of daily living. Despite these conditions, the resident was not present at the IDT care conference, and there was no documentation of the resident's refusal to attend. During interviews, Registered Nurse 1 confirmed that the IDT meeting was attended by nursing, dietary, and therapy staff, but not by the resident. The Director of Nursing stated that residents or their representatives should always be part of the IDT meetings, which are conducted upon admission and quarterly. The facility's policy on Comprehensive Care Planning, revised in 2017, also emphasized the importance of involving the resident or their family in care plan development. The failure to include Resident 26 in the care planning process violated their rights to be informed and to participate in their care plan.
Lack of Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically addressing the use of anticoagulant medication. The resident, who was admitted with acute respiratory failure and atrial fibrillation, was dependent on staff for all activities of daily living and had moderately impaired cognition. Despite having an order for Apixaban, an anticoagulant, to be administered via a gastrostomy tube, there was no care plan in place to guide the use of this medication. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed the absence of a care plan for the resident's anticoagulant use. The facility's policy requires a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's needs, but this was not implemented for the resident in question. This oversight had the potential to result in poor quality of care and a delay in necessary services.
Failure to Document COVID-19 Vaccination Status for All Staff
Penalty
Summary
The facility failed to provide documented evidence of COVID-19 vaccination status for all employees, including physicians and consultants, which is required to ensure the safety of residents and staff. During an interview and record review, the Infection Prevention Nurse (IPN) admitted to not knowing the COVID-19 immunization status of facility physicians and consultants. The Director of Nursing (DON) confirmed that the vaccination status of all employees, including those in contact with residents, must be known to prevent the risk of infection. The facility's policy, dated February 2025, mandates maintaining documentation of COVID-19 vaccination status for all staff, defined as anyone working or volunteering at the facility at least once a week, including contracted individuals. This lack of documentation potentially placed staff and residents at risk for negative health outcomes related to COVID-19.
Room Size Deficiency in Multiple Resident Bedrooms
Penalty
Summary
The facility failed to ensure that 20 out of 29 resident rooms met the regulatory requirement of providing at least 80 square feet per resident in multiple resident bedrooms. The rooms in question were designed to accommodate two residents each, but measurements revealed that the square footage per resident ranged from 69.16 to 79.6 square feet, falling short of the required space. This deficiency was identified through a review of the facility's Client Accommodations Analysis form, which detailed the specific measurements of each room. Despite the deficiency, observations and interviews conducted during the survey period indicated that residents did not experience difficulty moving in and out of their rooms, and there were no complaints regarding room size during the Resident Council meeting. The administrator acknowledged that some rooms were smaller than required but noted that residents were satisfied with the room size, and staff were able to provide adequate care. The report did not indicate any immediate negative impact on resident care or safety due to the room size deficiency.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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