Bixby Towers Post-acute Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 3747 Atlantic Avenue, Long Beach, California 90807
- CMS Provider Number
- 056283
- Inspections on file
- 42
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 28 (1 serious)
Citation history
Health deficiencies cited at Bixby Towers Post-acute Rehab during CMS and state inspections, most recent first.
A full-code resident with multiple medical conditions and a POLST requiring CPR was found unresponsive, not breathing, and pulseless by a CPR-certified CNA, who left the resident to seek help instead of activating a Code Blue, calling 911, and starting CPR. An LVN and RN later arrived with a crash cart but delayed CPR while attempting to obtain blood pressure, using a pulse oximeter, performing a sternal rub, and checking the resident’s eyes before confirming pulselessness and beginning chest compressions and rescue breathing. 911 was not called until several minutes after the initial discovery of unresponsiveness, and paramedics subsequently provided advanced resuscitation efforts before the resident was pronounced dead, leading surveyors to cite the facility for failing to follow its CPR policy and AHA BLS guidelines.
A resident with a POLST requiring CPR for cardiopulmonary arrest was found unresponsive, not breathing, and pulseless by a CPR-certified CNA, who did not call a code or begin CPR but left to get an LVN and did not return. An RN and LVN later entered the room with a crash cart, confirmed the absence of a pulse using a pulse oximeter and carotid check, and then initiated chest compressions and rescue breathing while another nurse called 911 several minutes after the initial notification. Facility policies required adherence to AHA BLS guidelines, immediate code activation, and prompt initiation of CPR by properly trained personnel, but interviews with staff and leadership showed that these procedures were not followed and that staff were not consistently competent in BLS and emergency response.
A resident with complex medical needs, including use of a life vest and requiring maximal assistance, eloped from the facility without staff awareness after exiting through an unsecured dining room door. Staff interviews revealed lapses in supervision, unclear monitoring responsibilities for certain facility areas, and failure to implement additional interventions despite observed risk behaviors. The resident was missing for several hours before being found by family.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as observed and documented by surveyors.
A resident did not receive the necessary care and services to maintain or improve ROM, limited ROM, or mobility, and there was no documented medical reason for the decline.
Surveyors observed an uncovered bowl of dry cereal stored past its use-by date and multiple expired, unlabeled canned food items in the emergency food supply. The Dietary Manager and DON confirmed that these practices did not follow facility policy and could result in expired food being served to residents.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility did not maintain or document preventive maintenance for three pieces of electrical rehabilitation therapy equipment, including an ultrasound unit, TENS combination unit, adjustable therapy mat, and a bicycle. Staff interviews revealed no process or records for routine checks, and policy reviews showed that required maintenance schedules and documentation were not followed.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft, as evidenced by gaps in staff training and unclear guidance on reporting and prevention. This created an environment where such incidents could occur without prompt detection or intervention.
Nurses and nurse aides lacked the necessary competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards for individualized resident needs.
A resident's Foley catheter drainage bag was found uncovered, contrary to facility policy requiring dignity bags to protect privacy and dignity. Staff interviews confirmed awareness of the policy and responsibility for compliance, but the omission was not noticed or corrected at the time.
A resident with severe cognitive impairment and significant care needs reported to the ADON that a CNA was rough with her during personal care. The resident's family also informed staff and provided a photo of the CNA. Despite these reports, the ADON did not notify required authorities, as she did not consider the incident abuse because the resident said she was fine. Other staff confirmed that such actions should be reported as abuse, but the facility failed to follow its abuse reporting policy.
A resident with severe cognitive impairment and high ADL needs was allegedly handled roughly by a CNA during incontinence care, as reported by the resident's family member to facility staff. Despite the report and facility policy requiring investigation of all abuse allegations, the ADON did not initiate an investigation, and the incident was not reported or documented as required. Staff interviews confirmed that such actions should be considered and treated as abuse.
The facility did not properly complete or document PASARR screenings for two residents with mental health conditions, resulting in missed or incorrect assessments following admission and readmission. Staff interviews confirmed that required screenings were either not done or documented inaccurately, contrary to facility policy.
A resident with severe cognitive impairment and arthritis reported physical abuse by a CNA during personal care. Despite this, staff did not develop or implement a care plan addressing the abuse allegation, as confirmed by record review and staff interviews. This failure resulted in the omission of necessary care and services.
A resident who was fully dependent on staff for ADLs and had chronic urinary incontinence was left in a wet adult brief for about an hour, resulting in distress. Staff acknowledged the need for a change but did not provide care at the time, citing the need for assistance. Facility policy and the resident's care plan required prompt incontinence care, but this was not followed.
A resident with multiple health conditions and a care plan indicating risk for dehydration did not have their water pitcher within reach, as required by physician orders and facility policy. The resident reported being unable to access water and feeling thirsty, and staff confirmed the water pitcher should have been accessible to prevent dehydration.
A resident with significant mobility limitations and a physician's order for PT and OT evaluation and treatment did not receive a PT evaluation as required. The order was not communicated to therapy staff, and the evaluation was not completed within the facility's required timeframe, resulting in a delay in necessary rehabilitative services.
The facility did not fully resolve previously identified deficiencies in resident rights, quality of care, food safety, and infection control. Despite regular QAPI meetings and involvement of leadership, ongoing issues were attributed to inconsistent staff education, lack of monitoring, and insufficient follow-through on corrective action plans.
The facility did not ensure that staff and family members wore required PPE while providing care or visiting two residents under enhanced barrier precautions due to indwelling medical devices. Observations showed that family members assisted a resident with a urinary catheter without PPE, and a CNA provided direct care to another resident with a G-tube without an isolation gown, contrary to facility policy and infection control protocols.
A resident with severe cognitive impairment and multiple medical conditions had a cell phone that was not documented on the belongings list and subsequently went missing. Staff interviews and policy review confirmed that all personal property should be inventoried and tracked, but this was not done, resulting in the loss of the resident's cell phone.
A resident with severe cognitive impairment and multiple care needs did not have their family’s request accommodated to ensure feeding and adult brief checks before Ativan administration. Documentation and staff interviews confirmed the absence of evidence that these steps were taken prior to giving the medication, despite facility policy requiring accommodation of individual needs and preferences.
A resident with severe cognitive impairment and incontinence was not provided toileting hygiene at least every two hours as required by their care plan. Documentation and staff interviews confirmed the resident was left in a soiled adult brief for extended periods, with feces and urine present, contrary to facility policy and care plan interventions.
A resident with severe cognitive impairment and dysphagia, who required substantial assistance, did not receive the physician-ordered oral gratification diet with pureed foods and thickened fluids for several days. Facility documentation and the DON confirmed that the resident was not assisted with meals as required, contrary to facility policy.
Three staff members, including a receptionist, a CNA, and a maintenance worker, were found not wearing required identification badges while on duty. The receptionist was awaiting her badge, the CNA forgot to wear hers, and the maintenance worker was not wearing his during rounds. This failure to follow facility policy did not support resident rights to know who was providing care and to be treated with respect.
A resident with metabolic encephalopathy and muscle weakness, who required partial assistance with daily activities, was found to have their call light out of reach during an observation. Both an LVN and the ADON confirmed that call lights should always be accessible, and facility policy requires staff to ensure this before leaving the room.
A resident with severe cognitive impairment and a history of falls did not have an extended floor mattress placed as required by their care plan, due to concerns about a roommate tripping. Staff found the resident on the floor after an unwitnessed fall, and the DON confirmed the intervention should have been implemented or alternatives considered.
Nursing staff transferred a resident with cognitive impairment and legal blindness into a Tilt-in-space wheelchair without prior training on its use. After being positioned upright, the resident began to slide down the chair. Both the CNA and LVN involved confirmed they had not received training on the equipment before the incident, contrary to facility policy requiring instruction for unfamiliar wheelchair models.
A resident with cognitive impairment and legal blindness was seen by ophthalmology and ENT specialists without the knowledge or authorization of their DPOA, despite clear documentation and staff awareness that the DPOA was to be notified and involved in all medical decisions beyond primary care, podiatry, and dental services. This failure resulted in a violation of the resident's rights.
A resident with cognitive impairment and legal blindness used a personal Tilt-in-space wheelchair, but facility staff did not obtain or follow the manufacturer's maintenance guidelines for the equipment. Both the DOR and Maintenance Supervisor confirmed the absence of the user manual, and maintenance was performed without reference to manufacturer instructions, contrary to facility policy.
The facility failed to report an Influenza A outbreak to CDPH immediately, involving two residents who tested positive. Despite positive test results, the outbreak was reported three days late, acknowledged by the IP Nurse as an oversight. This delay hindered CDPH's ability to investigate promptly.
A resident was denied readmission to a facility after being cleared by a GACH psychiatrist following a transfer for psychiatric evaluation due to inappropriate sexual behaviors. Despite having a bed hold policy, the facility cited safety concerns for other residents and refused readmission, lacking resources for a 1:1 sitter. The facility's policies on bed-hold and transfer documentation were not followed.
A resident with schizophrenia and cognitive impairments was left unsupervised with another resident, leading to two incidents of sexual abuse. Despite witnessing the first incident, staff failed to separate the residents, allowing a second assault to occur. The facility did not follow its policy on abuse reporting and investigation, resulting in a serious deficiency.
A facility failed to evaluate and treat a resident with schizophrenia and aggressive behaviors, leading to the resident assaulting another vulnerable resident twice. The resident was not assessed by a psychiatrist or prescribed necessary medications upon admission, resulting in unchecked aggressive behaviors. Staff failed to maintain supervision after the first incident, allowing a second assault to occur.
The facility failed to provide abuse training to two LVNs before they began direct patient care, as required by policy. The DSD could not find records of such training, which is mandatory upon hire and conducted twice a year. The Administrator confirmed the necessity of this training to prevent potential abuse risks.
The facility's QAA and QAPI committee failed to ensure the Medical Director attended monthly meetings, as revealed through interviews and record reviews. The DON admitted the MD's absence in July 2024 and did not relay meeting minutes to the MD. The Administrator stressed the MD's role in addressing medical concerns and implementing corrective actions, but the facility did not adjust the meeting schedule to fit the MD's availability.
Two LVNs at the facility were found to have provided direct patient care without receiving mandatory abuse training. The Director of Staff Development could not locate training records for these staff members, which is a requirement before they engage in resident care. The Administrator confirmed that abuse training is provided upon hire and biannually, and emphasized the necessity of this training to prevent potential abuse risks. The facility's policy requires regular in-service education, including abuse prevention, before staff provide services.
The facility failed to maintain a tracking system for staff participation and competency in its online learning program, risking resident safety. The DSD admitted to not keeping data on staff progress and not knowing how to retrieve lesson plans from the software. The Administrator confirmed the DSD's responsibility for maintaining the education program and expressed concern about the lack of tracking, which could lead to untrained staff providing inadequate care.
A facility failed to ensure a PCP signed admission orders for a resident with multiple diagnoses, including cerebrovascular disease and diabetes. Although the physician visited within the required 72 hours, they did not sign the necessary orders, as confirmed by the MRD and DON. The facility's policy mandates signed and dated physician orders to ensure appropriate care.
A resident who underwent left leg surgery did not receive a timely follow-up appointment with an orthopedic surgeon, resulting in the discontinuation of necessary physical therapy services. Despite the resident's admission with conditions requiring therapy, the facility staff failed to communicate the need for a follow-up consult, leading to a delay in treatment and potential decline in the resident's condition.
A resident with a history of BPH was not properly monitored for urinary retention, leading to a lack of urine output documentation for over 24 hours. CNAs did not report dry diapers to licensed nurses, and necessary assessments were not conducted. The resident was later transferred to a hospital with a UTI, severe sepsis, and significant urine retention.
A resident was prescribed and administered Seroquel without appropriate documentation of behaviors or non-pharmacologic interventions. The facility failed to conduct comprehensive evaluations to justify the medication's use, and the resident's psychiatrist made a preliminary diagnosis of schizophrenia to facilitate admission. The facility's policy on antipsychotic medication use was not followed.
Two residents were not treated with dignity in a LTC facility. A resident's bedside commode was not promptly cleaned, leading to feelings of sadness. Another resident, dependent on staff for eating, was fed by a CNA standing over them, contrary to facility policy. The DON confirmed these practices compromised resident dignity.
The facility failed to document advance directives and POLST for four residents, violating their rights to be informed about end-of-life care options. Despite having severe cognitive impairments and multiple diagnoses, these residents and their responsible parties were not provided with necessary discussions or documentation, as required by facility policy.
The facility did not provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents after their Medicare Part A coverage ended, as revealed during an interview and record review with the DON. The residents continued to stay at the facility without being informed of their financial liability and appeal rights.
The facility failed to maintain accurate medication counts and proper storage, leading to discrepancies in controlled medication for a resident, improper storage temperatures for two residents' medications, and expired medications in a cart affecting multiple residents. An LVN confirmed these issues, which were against the facility's medication storage policy.
The facility failed to ensure safe food storage practices, with unlabeled food in the refrigerator and staff personal items stored near food in the dry storage room. This could lead to cross-contamination and foodborne illnesses.
A resident with quadriplegia and spastic hemiplegia was not provided with a touch pad call light, leading to frustration and delayed care. Despite facility policies requiring functional call devices and accommodation of individual needs, the resident's inability to use the standard call light due to hand stiffness was not addressed, as confirmed by staff interviews and observations.
A resident on Xarelto, a blood thinner, had multiple skin discolorations that were not assessed or documented by facility staff, despite being at high risk for bleeding. The care plan required monitoring for bruising, but staff failed to follow the facility's policy for documenting and reviewing skin issues, leading to a deficiency.
A resident with hearing difficulties was not referred to an audiologist as required by her care plan, despite being identified as hard of hearing. Staff interviews confirmed the oversight, and the facility's policy emphasized the need for effective communication and necessary services for hearing-impaired residents.
Failure to Initiate Immediate CPR and Call 911 for Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely basic life support (BLS), including CPR, to a resident who was a documented full code, in accordance with the facility’s Cardiopulmonary Resuscitation policy and American Heart Association (AHA) guidelines. The resident had diagnoses including elevated white blood cell count, anemia, acute kidney failure, and chronic kidney disease, and had a POLST indicating that CPR was required in the event of cardiopulmonary arrest. On the night of the incident at approximately 10:30 p.m., a CPR-certified CNA found the resident unresponsive, not breathing, and without a carotid pulse after checking twice. Instead of activating a Code Blue, calling 911, and initiating CPR, the CNA left the resident’s room to get help from an LVN and did not return to the resident, continuing with her assignment. After the CNA reported that the resident was unresponsive, LVN 1 informed RN 1, and both went to the resident’s room with a crash cart while another LVN checked the resident’s code status in the medical record. When RN 1 and LVN 1 arrived, no other staff were present with the resident. RN 1 and LVN 1 then performed additional assessments before starting CPR: LVN 1 attempted to obtain a blood pressure and applied a pulse oximeter to the resident’s finger, while RN 1 performed a sternal rub and attempted to open the resident’s eyes to assess responsiveness. They were unable to obtain a blood pressure or detect a pulse with the pulse oximeter, and only then did RN 1 check the carotid pulse and confirm there was no pulse, at which point chest compressions were started and rescue breathing was provided. RN 1 stated that three to four minutes elapsed between the time LVN 1 notified her that the resident was unresponsive and the time 911 was called. The facility’s own CPR policy, based on AHA guidelines, required properly trained personnel to provide BLS, including CPR, prior to the arrival of emergency medical personnel, and to immediately initiate a Code Blue and activate emergency services in a cardiopulmonary emergency. The policy and AHA guidelines emphasized rapid assessment of responsiveness, breathing, and pulse, immediate activation of the emergency response system, and prompt initiation of chest compressions when no pulse is detected, without delaying CPR for additional assessments such as blood pressure measurement. In this incident, 911 was not called until 10:37 p.m., as confirmed by the Fire Call History, and paramedics were dispatched at 10:39 p.m. and arrived at the bedside at 10:49 p.m. The Paramedic Run Sheet documented that high-quality CPR, ventilation via bag-valve-mask, and cardiac epinephrine were provided, but resuscitation efforts were ultimately ceased, and the resident was pronounced dead at approximately 11:13 p.m. The surveyors determined that these failures resulted in a delay in calling 911 and initiating CPR for the resident and placed multiple full-code residents at risk of not receiving timely life-saving measures.
Failure to Initiate Timely CPR Due to Inadequate BLS Competency
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were competent in basic life support (BLS) and to initiate CPR without delay when a resident was found pulseless. The resident had been admitted with diagnoses including elevated white blood cell count, anemia, acute kidney failure, and chronic kidney disease, and had documented capacity to make medical decisions. A POLST form for the resident required CPR in the event of cardiopulmonary arrest. On the date of the incident at approximately 10:30 p.m., a CNA who was CPR certified found the resident unresponsive, not breathing, and without a carotid pulse after checking twice. Despite this, the CNA did not call a code blue or begin CPR, but instead left the room to get help from an LVN and did not return to the resident’s room, continuing with her assignment. Subsequently, the LVN informed an RN that the resident was unresponsive, and both went to the resident’s room with a crash cart. When they arrived, no other staff were present with the resident. The LVN checked the resident’s blood pressure and placed a pulse oximeter on the resident’s finger, while the RN attempted to assess responsiveness. The pulse oximeter did not detect a pulse, and the RN then checked the carotid pulse and confirmed there was no pulse. At that point, the RN initiated chest compressions and directed that 911 be called, while the LVN provided rescue breathing. According to the RN, three to four minutes elapsed between the time she was notified that the resident was unresponsive and the time 911 was called. Facility records, including the nursing progress note, fire call history, and paramedic run sheet, showed that 911 was called at 10:37 p.m., paramedics arrived at the bedside around 10:49 p.m., initiated high-quality CPR with ventilation via bag-valve mask and administered epinephrine, but there was no change in the resident’s condition, and resuscitation efforts were eventually stopped. The death certificate listed cardiopulmonary arrest as the immediate cause of death with arteriosclerotic cardiovascular disease as the underlying cause. Interviews with facility leadership and staff highlighted deviations from established policies and AHA BLS guidelines. The Director of Staff Development stated that when staff find a resident unresponsive, they should not leave the resident alone, should call a code blue or call for help, delegate someone to call 911 and get the crash cart, and initiate chest compressions immediately upon discovering no pulse. The DSD also stated that CNA 1 leaving the resident alone after finding no pulse did not follow AHA BLS guidelines. The DON stated she was not aware that the CNA had found the resident without a pulse before notifying the LVN and indicated it was acceptable for the CNA to leave to get help because the CNA could not initiate CPR without knowing the resident’s code status. The facility’s CPR policy required properly trained personnel to provide BLS, including CPR, prior to arrival of emergency medical personnel and to follow current AHA guidelines, including immediately initiating a code blue, activating emergency services, and concurrently assessing responsiveness, breathing, and pulse while initiating chest compressions. The AHA guidelines reviewed by surveyors specified that healthcare professionals should check for responsiveness, shout for help, activate the emergency response system, check breathing and pulse within 10 seconds, and, if no pulse is present, start CPR with 30 compressions to 2 breaths until an AED arrives. The facility’s competency and job description documents required nursing staff, including CNAs, LVNs, and RNs, to follow established policies and procedures, which did not occur in this event.
Resident Elopement Due to Inadequate Supervision and Exit Security
Penalty
Summary
A deficiency occurred when a resident with significant medical needs, including ventricular tachycardia, hypotension, depression, and the use of a life vest for cardiac risk, eloped from the facility without staff knowledge or supervision. The resident required substantial to maximal assistance with activities of daily living and was known to need continuous monitoring due to his medical condition and the use of a life vest. Despite these needs, the resident was able to exit the facility through the dining room exit doors in a wheelchair, as confirmed by video surveillance footage. Staff interviews revealed that the resident was last seen by a CNA during routine rounds and was later observed attempting to get out of bed and pull out his G-tube. This behavior was reported to nursing staff, but no further interventions were implemented. The CNA and LVN both stated that residents were not permitted to go downstairs unsupervised, and there was no nursing personnel assigned to the first floor to monitor residents in that area. The lack of supervision and unclear responsibility for monitoring residents on the first floor contributed to the resident's ability to leave the facility undetected. The facility's maintenance supervisor confirmed that while the dining room exit doors could be locked from the outside, they could be freely opened from the inside, allowing residents and visitors to exit at any time. The Director of Nursing acknowledged that the resident was unsupervised and away from the facility for approximately five hours. The facility's policy emphasized the importance of resident safety and supervision, but these measures were not effectively implemented, resulting in the resident's elopement.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. The report does not specify the particular medical history or condition of the resident at the time of the deficiency.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Improper Storage and Use of Expired Food Items
Penalty
Summary
The facility failed to properly store and manage food items in accordance with professional standards and its own policies. During an observation in the dry food storage room, an uncovered bowl of dry cereal was found on a tray labeled with dates that had already passed. The Dietary Manager (DM) discarded the cereal upon discovery, acknowledging it was past its use-by date. Additionally, in the facility basement, six cans of corned beef hash with expired dates and a box of canned pulled chicken with an expired date were found. These items were part of the emergency food supply and were not labeled, which the DM stated was necessary to prevent them from being circulated for resident consumption. Interviews with the DM and the Director of Nursing (DON) confirmed that expired and improperly stored food items could be present in the facility's food supply. The DM admitted that expired food in the emergency supply was being discarded slowly and recognized the risk of foodborne illness from consuming such items. The DON also acknowledged the potential for residents to experience symptoms such as stomach pain, diarrhea, nausea, vomiting, and even botulism from expired canned foods. Review of the facility's policy indicated that opened dry food items should be tightly closed, labeled, and dated, which was not followed in these instances.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Maintain and Document Preventive Maintenance of Therapy Equipment
Penalty
Summary
The facility failed to maintain three pieces of electrical rehabilitation therapy equipment, including an ultrasound unit, a TENS combination unit, an adjustable therapy mat, and a bicycle, for resident use. During an observation and interviews, the Rehabilitation Director was unable to provide records of maintenance or calibration for any of the therapy equipment and stated that neither therapy nor maintenance staff had checked or maintained the equipment. The Maintenance Director confirmed that there was no process in place for preventive maintenance checks on therapy equipment, and maintenance staff only responded to work orders if equipment was reported as broken. The Director of Nursing also acknowledged the importance of preventive maintenance to ensure resident safety during therapy sessions. A review of the facility's policies revealed that the Maintenance Director was responsible for developing and maintaining a schedule of maintenance services to ensure equipment was kept in a safe and operable condition. Additionally, policies required that inspections include checks of equipment functioning and general condition, with records kept for each piece of equipment. Despite these policies, there were no records or evidence of maintenance or inspection for the therapy equipment, indicating a failure to follow established procedures.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training and a lack of clear guidance on reporting and preventing such incidents. The absence of robust preventive measures contributed to an environment where abuse, neglect, or theft could occur without timely detection or intervention.
Inadequate Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest practicable level of physical, mental, and psychosocial well-being for residents. The report specifically notes that the staff's competencies were insufficient to ensure that all residents received care tailored to their needs, as required by regulatory standards.
Failure to Cover Foley Catheter Drainage Bag with Dignity Bag
Penalty
Summary
A deficiency was identified when a resident's Foley catheter drainage bag was observed to be uncovered, lacking the required dignity bag. During an observation and interview, a CNA confirmed that the dignity bag was not in place and acknowledged that it is the responsibility of all staff to ensure Foley catheter drainage bags are covered. The CNA was unable to provide a reason for the omission and recognized that leaving the drainage bag uncovered would be considered disrespectful to the resident. A treatment nurse also confirmed awareness of the facility's policy requiring dignity bags and acknowledged responsibility for ensuring compliance, but was unaware of the uncovered drainage bag at the time of the observation. Further interviews with the Director of Staff Development and the Director of Nursing confirmed that the facility's policy and procedure mandate the use of dignity bags on all Foley catheter drainage bags to maintain resident privacy and dignity. Both leaders stated that staff are trained on this requirement during orientation and ongoing education. A review of the facility's policy indicated that demeaning practices, such as failing to cover urinary catheter bags, are prohibited and that staff are expected to promote resident dignity by assisting with such measures.
Failure to Report Alleged Physical Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident with severe cognitive impairment and significant assistance needs for activities of daily living. The resident, who had diagnoses including osteoarthritis and rheumatoid arthritis, reported to the Assistant Director of Nursing (ADON) that a Certified Nurse Assistant (CNA) was rough with her while providing personal care. The resident's family member also reported the incident to staff and provided a photograph of the CNA involved. Despite these reports, the ADON did not report the allegation to the required authorities, stating that she did not consider the incident abuse because the resident said she was fine. Interviews with other staff, including another CNA and the Director of Staff Development (DSD), confirmed that being rough with a resident is considered a form of abuse and should be reported and investigated immediately. The Director of Nursing (DON) acknowledged that the allegation should have been reported and investigated, but at the time, it was not considered abuse. A review of the facility's abuse reporting policy indicated that all allegations of abuse must be promptly reported to the appropriate agencies, including the state licensing agency, the Ombudsman, and law enforcement, which was not done in this case.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its abuse prevention policy and procedure by not investigating an allegation of abuse involving a resident with severe cognitive impairment and significant assistance needs for activities of daily living. The resident's family member reported to staff that a CNA was rough while changing the resident's incontinent pad and provided a photo of the CNA involved. The family member stated they informed facility staff of the incident. Despite this, the Assistant Director of Nursing (ADON) did not report or investigate the allegation, stating that the resident said she was fine. Other staff, including a CNA and the Director of Staff Development (DSD), confirmed that being rough with a resident is considered abuse and should be reported and investigated immediately. The Director of Nursing (DON) acknowledged being informed that the resident was changed despite refusing care and agreed that the allegation should have been reported and investigated, but at the time did not consider it abuse. Review of the facility's policies confirmed the requirement to thoroughly investigate all allegations of abuse, including interviewing all involved parties and documenting evidence. The failure to follow these procedures resulted in the facility not investigating the reported incident of rough handling, contrary to its own abuse prevention and reporting policies.
Failure to Complete and Document PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) process was properly completed and documented for two residents with mental health diagnoses. For one resident admitted with depression, schizoaffective disorder, anxiety, psychosis, and insomnia, the facility did not resubmit a new Level I PASARR screening as required after an exempted hospital discharge. The resident's records indicated ongoing needs for nursing staff assistance with daily activities and the ability to make healthcare decisions, but the necessary PASARR review to determine appropriate services was not completed. For another resident with a diagnosis of schizophrenia, the PASARR Level I screening was documented incorrectly, indicating the resident did not have schizophrenia, despite medical records stating otherwise. This resident also required significant assistance from nursing staff for daily care. Interviews with facility staff confirmed that the PASARR screenings were either not completed or documented incorrectly, and that these omissions could affect the care and services provided to the residents. The facility's policy required coordination with the PASARR program and prompt referral for Level II review upon significant changes, but these procedures were not followed in these cases.
Failure to Develop and Implement Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who reported being physically abused by a Certified Nurse Assistant (CNA) during personal care. The resident, who had diagnoses of osteoarthritis and rheumatoid arthritis, was noted to have severe cognitive impairment and required maximal assistance with activities of daily living. Despite the resident's report of abuse to the Assistant Director of Nursing (ADON), a review of the resident's records confirmed that no care plan addressing the abuse allegation was created or implemented. Interviews with facility staff, including two Registered Nurse Supervisors (RNS) and the Director of Nursing (DON), confirmed that a care plan should have been developed following the abuse allegation to guide staff interventions and ensure the resident's safety. The facility's own policy required care plans to be updated when there is a significant change in a resident's condition, but this was not done in response to the reported abuse. This omission resulted in a failure to deliver necessary care and services as required.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for all activities of daily living, including toileting and personal hygiene, was not provided timely incontinence care. The resident, who had diagnoses including diabetes mellitus, seizures, hypertension, muscle weakness, and was always incontinent of urine, was observed crying in bed with a wet adult diaper. Both a Registered Nurse Supervisor and a Certified Nursing Assistant checked the resident and acknowledged the need for a diaper change but left the bedside without providing the necessary care. The Certified Nursing Assistant later stated she did not change the resident because she needed assistance, and confirmed that the resident should not have to wait for a diaper change. Interviews with staff confirmed that residents who are wet or soiled should be changed immediately to prevent complications such as skin irritation, yeast infections, and pressure ulcers. The facility's care plan for the resident specified that good skin care should be performed after each episode of incontinence. The facility's policy also required that residents receive care to maintain or improve their ability to carry out activities of daily living. Despite these requirements, the resident was left wet for approximately an hour, resulting in distress.
Water Pitcher Not Accessible to Resident at Risk for Dehydration
Penalty
Summary
A deficiency occurred when a resident's water pitcher was placed out of reach, contrary to the facility's policy and physician orders. The resident, who had diagnoses including dementia, Alzheimer's disease, hypertension, failure to thrive, and generalized muscle weakness, was assessed as being at risk for dehydration and was on a no added salt diet with extra hydration. The care plan and physician orders specifically indicated the need for additional hydration and that water should be encouraged and accessible. During observation, the water pitcher was found on the dresser, not within the resident's reach. The resident reported being unable to reach the water pitcher and expressed feeling thirsty as a result. Interviews with staff, including an LVN and the DON, confirmed that the water pitcher should have been placed within easy reach to prevent dehydration, in accordance with facility policy. The facility's policy and procedure for serving drinking water also required that the water pitcher and cup be placed within easy reach of the resident.
Failure to Provide Timely Physical Therapy Evaluation and Treatment
Penalty
Summary
The facility failed to provide a Physical Therapy (PT) evaluation and treatment as ordered by a physician for a resident with significant mobility and functional limitations. The resident, who had diagnoses including hemiplegia, hemiparesis, aphasia, and joint stiffness following cerebrovascular disease, was admitted and had a physician's order for PT and Occupational Therapy (OT) evaluation and treatment. Review of the resident's records showed that the PT evaluation was not completed, despite the order being present and the facility's policy requiring evaluations to be completed within 72 hours of the order. The Rehab Director confirmed that she was unaware of the order and that the nursing staff typically informs therapy of such orders, but this communication did not occur in this case. Observations of the resident revealed significant physical limitations, including a bent left elbow, fisted left hand, and limited movement in the right leg, consistent with the documented diagnoses and assessment findings. Interviews with facility staff, including the Rehab Director and DON, confirmed that the PT evaluation was missed and should have been completed as ordered. The facility's policy also required timely completion of such evaluations for residents referred by a physician, but this was not followed, resulting in a delay in the provision of necessary rehabilitative services.
Unresolved Deficiencies in Resident Rights, Quality of Care, Food Safety, and Infection Control
Penalty
Summary
The facility failed to correct deficiencies identified during the prior recertification survey conducted by the California Department of Public Health. These deficiencies were related to Resident Rights, Quality of Care, Food Safety, and Infection Control. The ongoing issues were confirmed through interviews and record reviews, which revealed that the facility's Quality Assurance and Performance Improvement (QAPI) program, although meeting regularly and including key leadership and department heads, did not fully resolve the previously cited deficiencies. The Administrator acknowledged that the QAPI committee reviews data, tracks trends, and conducts root cause analyses when issues are identified. However, the Administrator also stated that the previous deficiencies persisted due to inconsistent staff education, lack of monitoring, and insufficient follow-through on corrective action plans. As a result, the facility continued to have unresolved issues in ensuring resident dignity, quality care, food safety, and infection control.
Failure to Enforce Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to follow infection control precautions for two residents who were under enhanced barrier precautions (EBP) due to their medical conditions. One resident, admitted with hypertension and urinary retention and with a urinary catheter in place, had an active order for EBP. Despite this, observations on multiple occasions revealed that the resident’s family members were present at the bedside assisting with care without wearing the required personal protective equipment (PPE). Both the LVN and the Infection Prevention Nurse confirmed that family members should have been wearing PPE to prevent the spread of infection, as outlined in the facility’s infection prevention and control policy. Another resident, admitted with multiple diagnoses including dysphagia, a gastrostomy tube, myocardial infarction, depression, heart failure, and respiratory failure, also had an order for EBP. During care, a CNA was observed changing the resident’s gown and providing a bed bath without wearing an isolation gown, which is required under EBP protocols. The CNA acknowledged the omission and stated that gloves and an isolation gown should have been used. The Infection Prevention Nurse and the DON both confirmed that staff providing direct care to residents with indwelling devices or wounds must adhere to EBP, including the use of gowns and gloves. The facility’s policies and procedures for infection prevention and EBP were reviewed and both require the use of appropriate PPE by staff and visitors when providing care or having direct contact with residents under EBP. The observed failures to ensure compliance with these precautions for both staff and visitors constituted a deficiency in the facility’s infection prevention and control program.
Failure to Safeguard and Account for Resident's Personal Property
Penalty
Summary
The facility failed to ensure that a resident's personal possession, specifically a cell phone, was properly accounted for and kept safe. Upon review of the resident's admission record, it was noted that the resident, who had diagnoses including osteoarthritis, muscle weakness, dysphagia, metabolic encephalopathy, and dementia, was severely cognitively impaired and required substantial to total assistance with daily activities. The Minimum Data Set confirmed the resident's significant cognitive and physical limitations. Despite these needs, the belongings list for the resident did not include the cell phone, even though the resident had been using one prior to its disappearance. During interviews, an LVN acknowledged that the belongings list should have included the cell phone, and the DON confirmed that all residents are required to have a belongings list to track personal items. Review of facility policies indicated that personal property should be inventoried and documented upon admission and as items are replenished, and that residents' property should always be respected. The failure to document and track the cell phone resulted in its loss, demonstrating noncompliance with facility policy and the resident's right to have personal possessions respected and safeguarded.
Failure to Accommodate Resident and Family Preferences Prior to Medication Administration
Penalty
Summary
The facility failed to accommodate the specific needs and preferences of a resident as requested by the resident's family member. The resident, who had severe cognitive impairment, required substantial assistance with personal care and was dependent on staff for toileting and hygiene. The resident had a physician's order for Ativan to be administered via G-tube as needed for anxiety, with instructions to notify a family member prior to each dose. The family member also requested that the resident be fed and have their adult disposable diaper checked before Ativan was given. Record review and staff interviews revealed there was no documented evidence that the resident was fed or that their adult disposable diaper was checked prior to the administration of Ativan. Although the nurse stated the request was verbally communicated, it was not documented in the medical record or Medication Administration Record (MAR). The facility's policy required accommodation of individual resident needs and preferences to the extent possible, but this was not followed in this instance.
Failure to Provide Timely Toileting Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide toileting hygiene at least every two hours and as needed for a resident who was dependent on staff for activities of daily living. The resident, who had severe cognitive impairment, osteoarthritis, muscle weakness, dysphagia, metabolic encephalopathy, and dementia, was care planned to be checked and assisted with toileting every two hours due to incontinence. However, documentation and staff interviews confirmed that the resident was not checked or changed according to this schedule on all shifts. On one occasion, a family member assisted with toileting hygiene and found feces embedded in the vaginal area and urine leaking onto the wheelchair. A CNA confirmed that the resident's adult disposable brief was not checked for nearly three hours, during which time the resident was found soiled with urine and feces. The Assistant Director of Nursing reviewed records and confirmed the lack of timely checks and changes, and the Director of Nursing acknowledged that dependent residents need to be kept clean. The facility's policy required appropriate care and toileting assistance, which was not provided in this case.
Failure to Provide Ordered Oral Gratification Diet to Dependent Resident
Penalty
Summary
A resident with diagnoses including muscle weakness, dysphagia, metabolic encephalopathy, and dementia was admitted to the facility and assessed as having severely impaired cognition. The resident required substantial to total assistance with activities of daily living, including oral hygiene and eating. Physician orders were in place for an oral gratification diet with pureed texture and honey consistency fluids, intended to be provided three times daily. From June 1 to June 4, 2025, facility documentation and interviews confirmed that the resident was not assisted with meals during mealtimes as ordered. The Director of Nursing acknowledged that the resident did not receive the prescribed oral gratification diet during this period. Facility policies required that residents receive appropriate care and assistance with meals, but these were not followed for the resident in question.
Staff Failure to Wear Identification Badges Violates Resident Rights
Penalty
Summary
Three of five sampled staff members, including a receptionist, a certified nurse assistant (CNA), and a maintenance worker, were observed not wearing identification badges as required by the facility's policy. The receptionist stated she was new and still waiting for her badge to be issued. The CNA admitted to forgetting to wear her badge that day, and the maintenance worker indicated he was not wearing his badge while doing rounds in residents' rooms. These observations were confirmed during interviews with the staff involved. The facility's policy, updated in January 2021, mandates that all employees must wear a visible identification badge with their full name, position, and photo at all times while on the premises. The Assistant Director of Nursing (ADON) confirmed that all staff are expected to comply with this policy so residents can identify facility staff. The failure of these staff members to wear their badges did not support a culture of safety and transparency and violated residents' rights to know who was providing care and to be treated with respect.
Call Light Not Within Reach for Resident
Penalty
Summary
The facility failed to ensure that a call light was within reach for one of four sampled residents. The resident, who had diagnoses including metabolic encephalopathy and muscle weakness, was assessed as having intact cognition and required setup assistance with eating, oral hygiene, personal hygiene, and partial assistance with showering. During an observation and interview with a licensed vocational nurse, it was noted that the resident's call light was not accessible. Both the nurse and the Assistant Director of Nursing confirmed that call lights should always be within reach so residents can request assistance. Review of the facility's policy indicated that staff are required to ensure call lights are within residents' reach before leaving the room.
Failure to Implement Fall Prevention Intervention for High-Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident assessed as high risk for falls, who had a history of falling and severe cognitive impairment. The resident's care plan, revised after a previous fall, required the use of an extended floor mattress to provide protection in the event of a fall. Despite this intervention being documented, the mattress was not placed next to the resident's bed as required. On the date of the incident, staff responded to a bed alarm and found the resident on the floor without the extended mattress in place. Nursing notes indicated the mattress was not used due to concerns that the resident's ambulatory roommate might trip over it. The Director of Nursing confirmed that the care plan intervention should have been implemented, or alternative interventions considered if the mattress was not appropriate. The facility's policy required a resident-centered fall prevention plan for those at risk or with a history of falls.
Failure to Train Nursing Staff on Tilt-in-Space Wheelchair Use
Penalty
Summary
Nursing staff failed to receive proper training on the use of a Tilt-in-space wheelchair prior to its use for a resident with cognitive communication deficits, Alzheimer's disease, and legal blindness. The resident, who required maximum assistance for activities of daily living, was transferred from a mechanical lift into the Tilt-in-space wheelchair by a CNA and an LVN. After the transfer, the resident was positioned upright in the chair and began to slide down towards the floor, as documented in a witnessed fall report. Interviews with the CNA and LVN involved in the transfer revealed that neither had been trained on the use of the Tilt-in-space wheelchair before the incident. The Director of Rehabilitation confirmed that she had not provided training to the CNA prior to the event and stated that all staff should be trained on such equipment before use. The facility's policy required staff unfamiliar with a wheelchair model to receive instruction or guidance before use, but this was not followed in this case.
Failure to Notify DPOA Prior to Specialist Appointments
Penalty
Summary
The facility failed to ensure that a resident's appointed Durable Power of Attorney (DPOA), who was also a family member, was notified and authorized specialist medical appointments, as required by the resident's care plan and legal documentation. The resident, who had diagnoses including cognitive communication deficit, Alzheimer's disease, and legal blindness, was assessed as having mildly impaired cognition and required maximum assistance with daily activities. Documentation in the resident's records and interviews with staff confirmed that the DPOA had explicitly requested to be notified and to authorize any specialist visits beyond the primary care physician, podiatrist, and dentist/dental hygienist. Despite this, the resident was seen by an ophthalmologist and an ENT specialist without the DPOA's knowledge or documented authorization. Interviews with the MDS Coordinator and Social Services Director confirmed that staff were aware of the DPOA's role and the requirement to notify and obtain authorization for specialist visits. However, there was no documentation indicating that the DPOA was informed or had authorized the ophthalmology or ENT appointments. The facility's own policy stated that residents have the right to be informed of and participate in their care planning and treatment, and to appoint a legal representative. The failure to notify and involve the DPOA in these medical decisions resulted in a violation of the resident's rights.
Failure to Maintain Resident's Tilt-in-Space Wheelchair per Manufacturer Guidelines
Penalty
Summary
The facility failed to obtain and maintain the manufacturer's guidelines for a Tilt-in-space wheelchair used by a resident with cognitive communication deficit, Alzheimer's disease, and legal blindness. The resident required maximum assistance for activities such as toileting hygiene, showering, and dressing, and used a personal Tilt-in-space wheelchair. During interviews, both the Director of Rehabilitation and the Maintenance Supervisor confirmed they did not have the user manual for the wheelchair because it was owned by the resident. The Maintenance Supervisor acknowledged that although adjustments had been made to the wheelchair in the past to ensure it was working, the absence of the manufacturer's manual meant they could not be certain that all necessary maintenance and safety checks were performed according to the manufacturer's recommendations. The facility's policy required maintenance personnel to follow the manufacturer's recommended maintenance schedule for all equipment, but this was not done for the resident's wheelchair.
Delayed Reporting of Influenza A Outbreak
Penalty
Summary
The facility failed to report an Influenza A outbreak to the California Department of Public Health (CDPH) immediately, as required. This deficiency involved two residents who tested positive for Influenza A. Resident 9, who had chronic obstructive pulmonary disease and bronchitis, tested positive for Influenza A on February 15, 2025, after exhibiting flu-like symptoms. Similarly, Resident 10, diagnosed with asthma, tested positive for Influenza A on February 18, 2025. Despite these positive test results, the facility did not report the outbreak to CDPH until February 24, 2025, three days after Resident 10's positive test result. The delay in reporting was acknowledged by the Infection Prevention (IP) Nurse, who admitted forgetting to report the outbreak to CDPH promptly. The facility's policy and procedure for Infection Prevention and Control Program, dated March 6, 2025, clearly indicated that outbreak management involves reporting information to appropriate public health authorities. The failure to report in a timely manner resulted in CDPH being unaware of the outbreak and unable to investigate it promptly, potentially leading to the loss of pertinent information and unreported cases.
Facility Denies Readmission After Hospitalization
Penalty
Summary
The facility failed to uphold a resident's rights when they denied readmittance to a resident after hospitalization, despite the resident being cleared for return by a General Acute Care Hospital (GACH). The resident, who had been living in the facility for approximately 38 days, was initially transferred to the GACH for evaluation due to inappropriate sexual behaviors. The resident's medical history included schizophrenia, malignant neuroleptic syndrome, and diabetes mellitus type 2, and they had impaired cognitive skills for daily decision-making. The facility had informed the resident's conservator of the right to a bed hold for seven days in the event of hospitalization. However, after the resident was cleared by the GACH's psychiatrist for return, the facility refused readmission, citing concerns for the safety of other residents due to the resident's sexually impulsive behaviors. The facility's Director of Nursing and Administrator both expressed that the safety of current residents would be at risk if the resident were readmitted. The facility's policy and procedure on bed-hold and returns indicated that residents may return to the facility after hospitalization, but the facility did not have the resources to provide a 1:1 sitter to ensure safety. The GACH's discharge case manager confirmed that the facility refused to readmit the resident after being cleared, stating the resident was a danger to other residents. The facility's policy on transfer or discharge documentation required communication of the basis for transfer or discharge, including specific needs that could not be met, but this was not adhered to in this case.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, resulting in two incidents of non-consensual sexual contact. Resident 1, who had a history of schizophrenia and cognitive impairments, was admitted to the facility with a lack of awareness of place, location, and time. Despite these conditions, Resident 1 was left unsupervised with Resident 2, who had severe cognitive impairments and was dependent on staff for daily activities. This lack of supervision led to Resident 1 inappropriately touching Resident 2 on two separate occasions. The first incident occurred when a CNA found Resident 1 and Resident 2 in bed together, with Resident 1 engaging in inappropriate sexual behavior. The CNA reported the incident but left the residents alone in the room, contrary to the facility's policy that required separating residents involved in such incidents. This inaction allowed Resident 1 to assault Resident 2 a second time, as witnessed by another CNA who heard Resident 2 calling for help. The facility's policy on abuse reporting and investigation was not followed, as staff failed to separate the residents and provide necessary supervision. The DON acknowledged that Resident 1's impulsive behaviors were not managed, leading to the repeated assault on Resident 2. The facility's failure to adhere to its own procedures and ensure the safety of its residents resulted in a serious deficiency, as identified by the surveyors.
Removal Plan
- Ensure all residents are free from abuse through training addressing the critical elements of identifying all categories of abuse and the procedures for reporting abuse.
- Resident was discharged from the facility and sent to a General Acute Care Hospital for psychiatric evaluation and treatment.
- Resident was transferred to a General Acute Care Hospital for evaluation and returned to the facility.
- Upon Resident's return, the Social Services Director began monitoring for emotional distress, and Resident was seen by a Psychologist and Psychiatrist.
- The Social Services Director interviewed all cognitively aware residents and staff regarding any abuse incidents, with any issues identified to be investigated by the Abuse Coordinator/Administrator.
- All residents with psychiatric diagnoses admitted will be reviewed by the interdisciplinary team for their psychiatric and behavioral needs, including medication regimen and need for psychiatric consultation.
- Any residents admitted will be assessed by the interdisciplinary team for their medical, physical, and psychological needs and care planned accordingly.
- Staff training on abuse prohibition will consist of abuse prevention, identifying what constitutes abuse, recognizing signs of abuse, reporting abuse, understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond.
- The Director of Nursing, Director of Staff Development, and/or Clinical Resources will in-service and educate licensed nurses to review admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned.
- Facility staff will be in-serviced and educated on the immediate action required during an alleged abuse situation, including separating residents and providing immediate 1:1 supervision.
- Education and training for staff on leave, vacation, per diem or registry status will be completed prior to the start of their working shift.
- The facility Medical Director was notified of the Immediate Jeopardy and will continue to assist the facility to meet the needs of the Residents.
- Prior to the Quality Assurance Performance Improvement meeting, all training and education, including abuse, review of admission documents, separating residents, and all resident interviews regarding any alleged abuse, will be completed.
- The Immediate Jeopardy Removal Plan will be reviewed at the next scheduled QAPI Committee Meeting.
Failure to Manage Resident's Psychiatric Needs Leads to Assault
Penalty
Summary
The facility failed to ensure that a resident with a history of schizophrenia and aggressive, inappropriate sexual behaviors was properly evaluated and treated upon admission. The resident, who had been receiving Clozapine for disorganized thoughts and aggressive behavior at a previous facility, was not assessed by a psychiatrist or prescribed the necessary medications upon admission to the current facility. This oversight led to the resident not receiving any treatment for his schizophrenia since his admission. As a result of the facility's inaction, the resident sexually assaulted another resident twice. The first incident was witnessed by a Certified Nursing Assistant (CNA), who separated the residents but failed to maintain supervision. Shortly after, the resident assaulted the same individual again, which was witnessed by another CNA. The assaulted resident had severe cognitive impairments and was dependent on staff for daily activities, making them particularly vulnerable. The facility's failure to review the resident's psychiatric history and medication needs, as well as the lack of immediate and appropriate intervention by staff, resulted in the resident's aggressive behaviors going unchecked. This placed other residents at risk and led to the sexual assault of a vulnerable resident. The facility's Director of Nursing admitted to overlooking the resident's psychiatric history and failing to ensure the resident received the necessary behavioral care and services.
Removal Plan
- Ensure all residents are free from abuse through training addressing the critical elements of identifying all categories of abuse and the procedures for reporting abuse.
- Resident was discharged from the facility and sent to a General Acute Care Hospital for psychiatric evaluation and treatment.
- Resident was transferred to a General Acute Care Hospital for evaluation and returned to the facility.
- Upon Resident's return, the Social Services Director began monitoring Resident for emotional distress. Resident was seen by a psychologist and psychiatrist.
- The Social Services Director interviewed all cognitively aware residents and inquired if they have experienced abuse or know of any abuse in the facility. Staff were interviewed regarding residents who were not able to be interviewed.
- All residents with psychiatric diagnoses admitted will be reviewed by the interdisciplinary team for their psychiatric and behavioral needs, including their medication regimen and/or need for psychiatric consultation.
- Any residents admitted will be assessed by the interdisciplinary team for their medical, physical, and psychological needs and care planned accordingly.
- Staff training on abuse prohibition will consist of abuse prevention, identifying what constitutes abuse, recognizing signs of abuse, reporting abuse, understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond.
- The Director of Nursing, the Director of Staff Development, and/or Clinical Resources will in-service and educate licensed nurses to review admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned.
- The Administrator, the Director of Nursing, the Director of Staff Development or Clinical Resources will in-service and educate facility staff on the immediate action required during an alleged abuse situation.
- Education and training for staff on leave, vacation, per diem or registry status will be completed prior to the start of their working shift.
- The facility Medical Director was notified of the Immediate Jeopardy and will continue to assist the facility to meet the needs of the Residents.
- Prior to the Quality Assurance Performance Improvement meeting, all training and education which includes abuse, review of admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned, separating residents, immediately remove perpetrator from victim when indicated and provide immediate 1:1 supervision to keep a resident safe from any further alleged abuse, and all resident interviews regarding any alleged abuse, will be completed.
- This Immediate Jeopardy Removal Plan will be reviewed at the next scheduled QAPI Committee Meeting.
Failure to Provide Abuse Training to LVNs
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVN 1 and LVN 2) received abuse training before providing direct patient care. During a review of employee files by the Director of Staff Development (DSD), it was found that there was no record of abuse training for these two staff members. The DSD acknowledged that employees must undergo abuse training prior to engaging in direct resident care, and the absence of such training could potentially place residents at risk for abuse. The Administrator confirmed that the DSD is responsible for maintaining the facility's education program and hiring frontline staff. The Administrator also stated that abuse training is mandatory upon hire and is conducted twice a year. The facility's policy requires all staff to participate in regular in-service education, which includes training on preventing abuse, neglect, exploitation, and misappropriation of resident property. This training is required before staff provide services to residents, annually, and as necessary based on facility assessment.
Medical Director's Absence in QAA Meetings
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to ensure the Medical Director (MD) attended the monthly meetings. This deficiency was identified during interviews and record reviews conducted with the Director of Nursing (DON) and the Administrator. The DON acknowledged that the MD's attendance is crucial for addressing medical concerns and conducting root cause analyses of issues within the facility. However, the MD did not attend the QAA meeting in July 2024, and the DON admitted to not informing or relaying the meeting minutes to the MD. The Administrator emphasized the importance of the MD's presence at these meetings, as the MD is a key member of the governing body responsible for implementing corrective actions. The facility's policy and procedure for the QAPI program, effective since February 2023, outlines the necessity of data-driven, facility-wide processes to improve the quality of care and outcomes for residents. Despite this, the facility failed to adjust the meeting schedule to accommodate the MD's availability, leading to a lack of collaboration and potential oversight in addressing systemic problems.
Failure to Provide Abuse Training to LVNs Before Direct Care
Penalty
Summary
The facility failed to ensure that two Licensed Vocational Nurses (LVN 1 and LVN 2) received mandatory abuse training before providing direct patient care. During an interview and record review with the Director of Staff Development (DSD), it was revealed that the training records for these two staff members were missing. The DSD acknowledged that employees must complete abuse training prior to engaging in direct resident care, and the absence of such training could potentially place residents at risk for abuse. The Administrator confirmed that the DSD is responsible for maintaining the facility's education program and hiring frontline staff. The Administrator also stated that abuse training is required upon hire and biannually, emphasizing that staff must be trained before providing direct care to residents. The facility's policy, dated August 2022, mandates regular in-service education for all staff, including training on preventing abuse, neglect, exploitation, and misappropriation of resident property. This training is required before staff provide services to residents, annually, and as needed based on facility assessment.
Failure to Track Staff Competency in Online Learning
Penalty
Summary
The facility failed to maintain a tracking system for staff participation and competency in its online learning program, which is essential for ensuring the safety of residents. During an interview with the Director of Staff Development (DSD), it was revealed that she was responsible for managing the education program but did not keep any data regarding staff progress in the online learning system. The DSD admitted to not being able to retrieve lesson plans from the online education software and acknowledged the need to learn how to use the software better. This lack of tracking and competency assessment posed a risk to resident safety, as untrained staff might not provide appropriate care. The Administrator confirmed that the DSD's role included maintaining the facility's education program and ensuring staff competency through the online learning application. The Administrator expressed concern that without proper tracking, it was possible to overlook which staff members completed the necessary in-services. The facility's policy on staffing and competency emphasized the importance of tracking mechanisms to evaluate training effectiveness, yet this was not being implemented. The deficiency highlighted the potential risk to residents if staff were not adequately trained to manage their medical conditions.
Physician's Failure to Sign Admission Orders
Penalty
Summary
The facility failed to ensure that the primary care physician (PCP) signed the admission orders for a resident who was admitted from the hospital. This oversight involved a resident with multiple diagnoses, including cerebrovascular disease, diabetes mellitus, and vascular dementia. The resident was admitted on a specific date, and the facility's policy required the physician to visit within 72 hours of admission to evaluate the resident's condition, perform a History and Physical (H & P), and sign the Physician Orders (PO). However, the PCP did not sign the admission orders, which is a necessary step to ensure the resident receives appropriate medical intervention during their stay. Interviews with the Medical Records Director (MRD) and the Director of Nursing (DON) confirmed that the physician visited the facility within the required timeframe but failed to sign the necessary orders. The facility's policy, dated November 2014, mandates that physician orders and progress notes must be signed and dated. The DON acknowledged the responsibility to ensure compliance with this regulation, emphasizing the importance of the physician's visit and signature to provide appropriate care and services to the resident.
Failure to Schedule Follow-Up Appointment and Continue Therapy Services
Penalty
Summary
The facility failed to schedule a follow-up appointment with an orthopedic surgeon for a resident who had undergone left leg surgery. This oversight resulted in the resident not being cleared to continue receiving necessary physical therapy services. The resident, who was admitted with conditions including acute osteomyelitis of the left femur and muscle contracture, was initially receiving physical therapy until it was discontinued. The resident expressed concerns about the lack of therapy, stating that his strength was deteriorating due to inactivity. Interviews with facility staff revealed that the Director of Rehabilitation acknowledged the cessation of therapy services and noted that an order for physical and occupational therapy was received but not acted upon. The Registered Nurse Supervisor indicated that the hospital's referral documents included a post-surgery follow-up plan, which was not communicated to the admitting physician. The Director of Nursing confirmed that the nursing staff did not notify the physician about the need for an orthopedic consult, as they believed the resident was improving. The facility's policies and procedures were reviewed, highlighting the responsibilities of the Case Manager and Director of Rehabilitation in coordinating care and ensuring follow-up appointments. However, these procedures were not followed, leading to a lapse in the resident's care. The failure to arrange the necessary follow-up appointment and continue therapy services resulted in a delay in treatment and placed the resident at risk of further decline.
Failure to Monitor Urinary Retention and Hydration
Penalty
Summary
The facility's nursing staff failed to adequately monitor and assess a resident at risk for urinary retention due to benign prostatic hypertrophy (BPH). The staff did not report or act upon the resident's dry diaper, indicating no urine output, over an extended period. Certified Nursing Assistants (CNAs) did not report the absence of urine output to licensed nurses, and the licensed nurses did not conduct necessary physical assessments to check for signs of urinary retention, such as abdominal distension or pain. This lack of communication and assessment led to the resident not having documented urine output for over 24 hours. The resident, who had a history of BPH and was at risk for urinary retention, was admitted with diagnoses including secondary malignant neoplasm of the brain and acute kidney failure. Despite the care plan indicating the need to observe and report decreased urine output, the facility failed to ensure that the nursing staff followed these directives. The resident's fluid intake was documented, but there was no documentation of fluid output, and the resident was noted to be incontinent on several occasions without any recorded urine output. The deficiency resulted in the resident being transferred to a General Acute Care Hospital after suffering a seizure. At the hospital, the resident was diagnosed with a urinary tract infection, severe sepsis, and urine retention, with a significant amount of urine retained in the bladder. Interviews with staff revealed a lack of awareness and communication regarding the resident's condition and care plan, contributing to the failure to monitor and address the resident's urinary retention and hydration status effectively.
Failure to Document Appropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident, who was prescribed and administered the antipsychotic medication Seroquel, received the medication for appropriate indications. The resident was admitted with diagnoses including secondary malignant neoplasm of the brain and traumatic hemorrhage of the right cerebrum with loss of consciousness. Despite these conditions, there was no documentation of behaviors related to a diagnosis of schizophrenia, which was the stated reason for the Seroquel prescription. The medication was administered multiple times without detailed evidence of the resident's behaviors or attempts at non-pharmacologic interventions. The facility's records lacked documentation of a comprehensive evaluation by a physician, psychiatrist, psychologist, or nursing staff to determine the necessity of Seroquel for the resident. Interviews revealed that the resident's family member stated there was no history or diagnosis of schizophrenia. The Assistant Director of Nursing acknowledged that non-pharmacologic interventions should have been attempted and documented prior to administering antipsychotic medications, but this was not done for the resident in question. The resident's psychiatrist indicated that the resident was diagnosed with delirium and psychosis in the hospital, but due to the acute nature of delirium, a preliminary diagnosis of schizophrenia was made to facilitate admission to the facility. The psychiatrist ordered Seroquel for paranoia and agitation based on a report from the facility but did not have the opportunity to assess the resident personally. The facility's policy required that antipsychotic medications be used only for documented conditions and that non-pharmacological interventions be attempted and documented, which was not adhered to in this case.
Failure to Maintain Resident Dignity in Care Practices
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity. Resident 80 experienced neglect when their bedside commode, which contained feces, was not promptly emptied and cleaned by the nursing staff. Despite having the ability to understand and express ideas, Resident 80 reported feeling sad due to the delay in cleaning the commode, which sometimes took up to four hours or until the next day. This issue was confirmed during an observation where a plastic bag filled with feces was found in the commode, and a CNA admitted to being too busy to clean it immediately. The Director of Nursing acknowledged that the commode should be cleaned right away to prevent odor and maintain dignity. Additionally, Resident 30, who was dependent on staff for eating and lacked the capacity to make decisions, was fed by a CNA who stood over them instead of sitting at eye level. This practice was against the facility's policy, which emphasizes the importance of sitting at eye level to promote engagement and respect. The CNA admitted to not sitting due to the unavailability of chairs, while another CNA and the DON confirmed that sitting at eye level is necessary to make residents feel respected and to properly assess them during feeding.
Failure to Document Advance Directives and POLST
Penalty
Summary
The facility failed to ensure that the medical records of four residents included documentation of advance directives and physician orders for life-sustaining treatment (POLST). This deficiency was identified through interviews and record reviews, revealing that the facility did not provide or discuss the necessary documentation with the residents or their responsible parties. This oversight violated the residents' rights to be informed about their options for end-of-life care and to have their wishes documented and respected. Resident 77 was admitted with diagnoses including adult failure to thrive and dementia. Although an Advance Directive Acknowledgement was signed, the facility did not ensure that the necessary discussions and documentation were completed. Resident 85, admitted with chronic cholecystitis and hypertension, did not have an Advance Directive Acknowledgement on record, and the Social Services Director admitted to not assisting in formulating an advance directive for this resident. Resident 82, with severe cognitive impairment and multiple diagnoses, did not have a valid advance directive or POLST. The responsible party was not informed about these documents upon admission. Similarly, Resident 45, who was severely impaired and receiving hospice care, did not have an Advance Directive Acknowledgement on file. The facility's policy required that residents and their families be provided with information about their rights to formulate an advance directive, which was not adhered to in these cases.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), form CMS-10055, to two residents when their Medicare Part A coverage ended, and they continued to stay at the facility. During an interview and record review with the Director of Nursing (DON), it was revealed that Resident 2's last covered day for Medicare Part A Skilled Services was on January 19, 2024, and Resident 27's last covered day was on February 5, 2024. Despite the end of coverage, both residents remained at the facility without receiving the required SNF ABN, which would have informed them of their financial liability and appeal rights. The DON acknowledged that the facility did not provide the necessary notifications to these residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the accurate count and proper storage of medications, leading to several deficiencies. For Resident 32, there was a discrepancy in the controlled medication count of lorazepam, where the bottle contained 8 mL instead of the 4 mL documented on the controlled drug reconciliation record. This discrepancy was identified during an observation and interview with an LVN, who acknowledged the error and highlighted the potential risk of seizures or anxiety if the medication was not administered as recorded. On the second floor, the facility did not store medications according to the manufacturer's requirements. Resident 447's arformoterol tartrate inhalation solution was found without an open date label, and the refrigerator temperature was below the recommended range, potentially compromising the medication's effectiveness. Similarly, Resident 53's semaglutide was stored in a refrigerator that was too cold, which could alter the medication's chemical composition, as noted by an LVN during an interview. Additionally, expired medications were found in a medication cart on the third floor, affecting multiple residents. Medications with expiration dates ranging from May to June 2024 were still present, including those for Residents 36, 40, 19, and 32. An LVN confirmed that these expired medications should have been discarded, as their efficacy could be reduced, impacting the residents' treatment. The facility's policy on medication storage, which mandates proper labeling and disposal of expired medications, was not adhered to, contributing to these deficiencies.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices in the kitchen, as observed during a survey. In the walk-in refrigerator, a bag of salad was found without an open date label, which is necessary to track when the food was received and when it should be discarded. This oversight was acknowledged by a staff member, who confirmed the importance of labeling to prevent serving potentially expired food to residents, who are at high risk for foodborne illnesses. Additionally, in the dry storage room, staff personal items were improperly stored near food items. A personal bag and a hat belonging to a dietary aide were found on a shelf beside food products, such as elbow macaroni and spaghetti noodles. The dietary aide admitted to storing personal items in the dry storage room but could not explain why this practice was inappropriate. The dietary manager and another dietary aide confirmed that personal items should be kept in staff lockers to prevent cross-contamination with resident food.
Failure to Provide Appropriate Call Light for Resident with Quadriplegia
Penalty
Summary
The facility failed to provide a touch pad call light for a resident with quadriplegia, bipolar disorder, and spastic hemiplegia, who was unable to use the standard push button call light due to stiff and rigid hands. This deficiency was identified through observations, interviews, and record reviews. The resident expressed frustration over the inability to use the call light, which led to delays in receiving care. The resident's Minimum Data Set indicated impairments in both upper and lower extremities, requiring a two-person assist for activities of daily living, bed mobility, and transfers. Interviews with facility staff, including a CNA and an LVN, confirmed the resident's inability to effectively use the current call light system due to hand spasms and stiffness. The facility's policies and procedures on call systems and accommodation of needs were reviewed, indicating that residents should be provided with functional call devices and that individual needs and preferences should be accommodated. Despite these policies, the facility did not identify and address the resident's need for a touch pad call light, resulting in the deficiency.
Failure to Monitor Skin Discolorations in High-Risk Resident
Penalty
Summary
The facility staff failed to assess and monitor multiple skin discolorations for a resident identified as being at high risk for bleeding. The resident, who was on Xarelto, a blood thinner, had skin discolorations on the left hand, right arm, and left upper arm, which were not documented or assessed by the staff. The resident's care plan required staff to observe and report signs and symptoms of bruising, but there was no documentation of skin assessments after a certain date, despite the resident's condition and medication increasing the risk of bleeding. During interviews and record reviews, it was revealed that the Licensed Vocational Nurse (LVN) and Certified Nurse Assistant (CNA) did not document or report the skin discolorations. The Director of Nursing (DON) confirmed that the care plan required monitoring of the resident's skin due to the anticoagulant use, and acknowledged that bruising could worsen and lead to bleeding. The facility's policy required CNAs to document skin issues and for LVNs/RNs to review and sign off on these forms, but this process was not followed, leading to the deficiency.
Failure to Address Hearing Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident with hearing difficulties received the necessary services and treatment to address her hearing loss. The resident, who was admitted with various medical conditions including cellulitis, ulcerative proctitis, and generalized abdominal pain, was identified through the Minimum Data Set (MDS) as having difficulty hearing. Despite this, the resident was not referred to an audiologist as indicated in her care plan. Interviews with staff, including a CNA, LVN, and RNS, confirmed that the resident was hard of hearing and did not use a hearing aid. The staff acknowledged that the resident's hearing issues should have been reported to the social worker for a referral to an audiologist. The Social Services Director and the Director of Nursing both stated that residents with hearing problems should be seen by an ENT doctor or audiologist to determine if a hearing aid is needed. The facility's policy and procedure for hearing-impaired residents emphasized the importance of maintaining effective communication and arranging necessary services. However, the resident's hearing issues were not addressed, potentially impacting her ability to communicate effectively with staff and understand the care being provided.
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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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