Buena Vista Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Barbara, California.
- Location
- 160 South Patterson Avenue, Santa Barbara, California 93111
- CMS Provider Number
- 555394
- Inspections on file
- 39
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Buena Vista Care Center during CMS and state inspections, most recent first.
Failure to Document Blood Sugar Monitoring Before Insulin Administration: A resident with DM had a physician order for bedtime insulin, but the MAR showed no documentation that blood sugar checks were completed before several evening doses when the resident refused. There was also no documentation of the refusals, education attempts, or physician notification, and the DON confirmed this was not documented in the record.
Improper Medication Refrigerator/Freezer Storage: A medication storage room had a single-door refrigerator/freezer unit instead of the pharmacy-grade two-door unit described in facility policy. Surveyors observed ice buildup in the freezer, and the ADM acknowledged the unit did not have separate doors for the refrigerator and freezer sections.
A resident admitted with acute kidney failure had a dietary order for no added salt, fluid restriction, thin liquids, and a renal diet. During tray line observation, the meal ticket listed a regular diet and the tray included a salt packet, which the DM validated. The resident’s order and the renal diet guidance both called for low salt restrictions.
Food safety was not maintained when an outdated bottle of juice remained in the refrigerator and spoiled cucumbers were left for use. During kitchen observation, the DM identified the expired juice and moldy, mushy produce, and stated that the person receiving produce should inspect foods before storage or use. Facility policies required checking produce for spoilage and discarding spoiled items, and stated that use-by dates indicate when food must be consumed or discarded.
A resident admitted after a fall with a subdural hematoma and status post craniotomy had a right temporal surgical incision documented as present on admission, but LNs repeatedly recorded that wound measurements were not taken because the resident wanted to rest and then copied this same note over several days. No wound measurements or detailed incision descriptions were completed, no care plan was developed to address treatment or monitoring of the incision, no hand-off documentation supported continuity of care, and there was no evidence the physician was notified about the wound, despite facility expectations and policy for comprehensive, individualized care planning and wound assessment.
A resident with alcohol and opioid dependence did not receive a comprehensive, person-centered care plan addressing their substance use needs. The facility failed to connect the resident to support groups, did not implement or document care plan interventions, and did not obtain necessary physician orders for medication to reduce cravings. Staff were not trained on substance abuse or overdose response prior to the resident experiencing a heroin overdose, and the care plan was not updated after the incident.
A resident with moderate cognitive impairment and a history of elopement, who was equipped with a Wander Guard device, was able to leave the facility unmonitored. Staff failed to check the Wander Guard as ordered, and the resident accessed an unsupervised smoking area lacking a Wander Guard sensor. The resident was later found offsite and returned by police, with records and interviews confirming lapses in supervision and device monitoring.
The facility did not conduct daily functional testing of the Wander Guard system for seven residents as required by the manufacturer's instructions, instead performing checks weekly and documenting results accordingly. Interviews with nursing staff and the DON confirmed the deviation from the required daily testing protocol.
A resident admitted for post-joint replacement care did not receive prescribed pain medication until the day after admission, despite vocal complaints of pain and physician orders for acetaminophen and Roxicodone. The DON confirmed that the required medication was available in the emergency supply but was not administered as per facility policy.
A resident with dysphagia and a feeding tube had conflicting orders in their medical record, with an NPO status but antibiotics ordered to be given by mouth. Nursing staff administered the medications via gastric tube without clarifying the order with the physician, and the error was not identified or corrected in a timely manner.
A facility failed to maintain a resident's restroom in good repair, compromising the resident's right to a safe and homelike environment. Observations revealed peeling paint, an inoperable ceiling fan, a toilet seat partially without its outer coating, and a loose toilet lever. Staff confirmed these issues and acknowledged the absence of work orders to address them, contrary to the facility's Preventative Maintenance policy.
A resident with hemiplegia, dysphagia, and pressure injuries did not receive consistent care plan interventions for feeding assistance and pressure injury prevention. Documentation was missing for meal intake and the presence of pressure redistribution devices on several occasions, indicating potential lapses in care.
A facility failed to position a wound vacuum pump according to manufacturer guidance for a resident. The NPWT device's pump was observed on the floor next to the resident's bed, with cables and a tube in contact with the observer's feet. Manufacturer guidance specified that the system should be positioned to avoid trip hazards. The DON acknowledged the risk of tripping or disconnection.
The facility failed to ensure dietary staff wore hair restraints during meal service, as required by policy. Observations showed two staff members without facial hair restraints while preparing meals. Interviews revealed confusion about the policy's requirements, with the Dietary Manager admitting a lack of clarity and the Administrator confirming that restraints should be worn.
A resident with Parkinson's disease and type 2 diabetes was not assessed for self-administration of medication, as required by facility policy. Despite having a BIMS score indicating intact cognition, the resident was found with a bottle of multivitamins on their bedside table, which they were taking without an assessment or approval. Facility staff confirmed the lack of assessment and stated the resident was not permitted to have the multivitamin in their room.
A facility failed to accurately code a resident's MDS, omitting hospice care despite documentation indicating its initiation. The MDS Coordinator acknowledged the oversight, and the DON and Administrator stressed the importance of MDS accuracy for care planning and reimbursement.
A facility failed to resubmit a Level I PASARR screening for a resident with depression and anxiety disorder who stayed beyond 30 days, as required by policy. Staff interviews revealed a lack of awareness and oversight regarding the need for a new screening, resulting in non-compliance with state requirements.
A resident with Parkinson's disease and type 2 diabetes was found to have a bottle of multivitamins on their bedside table, contrary to facility policy requiring secure storage. The resident, with intact cognition, stated they took the multivitamin because it was all-natural. An LVN confirmed the improper storage, and the administrator noted that medications should be secured in the bedside drawer.
A resident with intact cognition and a history of cerebral infarction experienced an unwitnessed fall while self-transferring, resulting in a skin tear. The facility failed to notify the resident's designated responsible party, despite policy requirements and the resident's Power of Attorney granting the RP authority to receive such notifications.
The facility failed to assist a resident in making an outside appointment for a cataract evaluation as per the prescriber's order. The Administrator confirmed that there was no documentation showing that staff had attempted to make the appointment before the resident was discharged. The job description for the Social Services Assistant included coordinating such appointments, and the facility's policy emphasized the resident's right to access outside services.
The facility failed to maintain a system for accounting and managing a resident's personal funds. A resident with intact cognitive abilities left $300 with the Social Services Assistant (SSA) without a signed agreement or accounting statement. The SSA kept the money in a locked safety deposit without any accounting system, and the Director of Social Services (DSS) and Administrator confirmed the absence of such a system.
Failure to Document Blood Sugar Monitoring Before Insulin Administration
Penalty
Summary
Facility staff failed to follow physician orders for Resident 11, who was admitted with diagnoses including type 2 diabetes mellitus. The physician order dated 10/6/25 directed administration of Insulin Glargine solostar pen-injection 100 unit/ml, 22 units at bedtime for DM. Review of Resident 11's MAR showed no documentation that blood sugar was taken before the 9 p.m. insulin dose on 4/1/26, 4/3/26, 4/4/26, 4/5/26, and 4/8/26 prior to resident medication refusals. There was also no documentation related to the omission or that the physician was notified that Resident 11 refused blood sugar checks on those dates. The resident's care plan identified DM with potential for hypo/hyperglycemia and included interventions to identify areas of non-compliance, modify problem areas to make them more manageable, provide documentation teaching to the resident/family, and address identified roadblocks to compliance. During interview and record review, the DON confirmed it was the facility's standard practice to obtain a blood sugar reading before insulin administration and stated that when a resident refuses blood sugar checks or insulin, staff are expected to educate the resident, attempt compliance, notify the physician, and document all interventions; the DON acknowledged there was no documentation in the record to reflect blood sugar monitoring, education, attempts to obtain compliance, or physician notification.
Improper Medication Refrigerator/Freezer Storage
Penalty
Summary
The facility failed to follow its established policies for storing pharmaceutical products when a medication storage room in Station A was equipped with a single-door refrigerator/freezer unit instead of a pharmacy-grade two-door unit with a separate freezer compartment and door. During observation, the refrigerator used for medication storage had one door for both the refrigerator and freezer sections, and ice buildup was observed in the freezer. During interview, the administrator stated that the facility did not store medication in the freezer and acknowledged that the facility’s policy was to provide a pharmacy-grade refrigerator specifically for medications to preserve efficacy, with separate doors for the freezer and refrigerator. Review of the facility’s policy and procedure titled Monitoring for Monitoring of Temperature in Refrigerator/ Freezer Containing Pharmaceutical Products, dated 2018, stated that refrigerators and freezers used to store pharmaceutical products ideally shall be pharmacy grade and be a two-door unit with a separate freezer compartment and door when combined.
Dietary Order Not Followed for Resident on Renal Diet
Penalty
Summary
The facility failed to meet the dietary prescription for one resident, who was admitted with diagnoses including acute kidney failure, unspecified. During a concurrent observation and interview at the tray line, the meal ticket for the resident indicated Regular, Fluid Restriction 1500 ml Thin Liquids, and Renal Diet, and the tray was observed with a salt packet; the Dietary Manager validated this observation and stated they would double check the dietary prescription. During a later interview and record review, the resident’s dietary order was reviewed and showed No added Salt. A review of the facility’s Renal Diet 40-60-80 Gram Protein Low Potassium, Low Salt Menu stated that the diet should include restrictions such as potassium, sodium, and fluid, with low potassium and low salt recommended.
Food Storage and Dating Deficiency
Penalty
Summary
Food safety was not maintained when an outdated bottle of juice was left in the refrigerator and spoiled produce was left for use instead of being discarded. During a concurrent observation and interview in the kitchen, a bottle of juice was found in the refrigerator with a best by date of 4/1/26. In a separate concurrent observation and interview, cucumbers were noted to have mold and to be mushy. The Dietary Manager stated that the person responsible for receiving produce should inspect foods before storage or use. Facility policies titled Storing Produce and Labelling and Dating of Foods stated that fruit and vegetables should be checked for rotten or spoiled items, spoiled items should be thrown away upon delivery, and food use-by dates indicate when food must be consumed or discarded.
Failure to Assess and Care Plan Surgical Incision on Admission
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure licensed nurses completed wound assessments and developed a care plan for a resident’s surgical incision upon admission. The resident was admitted with diagnoses including post-fall, subdural hematoma, and status post craniotomy, and the admission History and Physical documented a right temporal surgical incision present on admission. An initial body assessment on the admission date noted a new surgical wound on the right temporal area, identified as a surgical wound present on admission, but stated that measurements were not documented because the resident wanted the assessment done another day and wanted to rest. From the admission date through several subsequent days, progress notes repeatedly documented the same entry about the new surgical wound, its location, and that measurements were not taken for the same stated reason. There was no evidence in the medical record that wound measurements or a detailed description of the incision were ever completed during this period. The record also lacked a care plan addressing the surgical incision, including treatment or monitoring interventions, and there were no hand-off reports or documentation to support continuity of care among staff regarding the wound. Additionally, there was no documentation that the physician was notified about the surgical incision. In interviews, an RN described the facility’s usual process for residents with wounds, including admission assessment, notification of the treatment nurse, completion of a full assessment within 24 hours, and notification of the physician and family, and stated that nothing had changed in how wound assessments were to be done. The DON acknowledged that the resident’s medical record was missing the surgical wound assessment and confirmed there was no care plan developed for the incision, despite the facility’s care plan policy requiring individualized, comprehensive care plans for identified resident problems.
Failure to Implement Comprehensive Care Plan for Resident with Substance Use Disorders
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with known alcohol dependence, alcohol abuse, and opioid dependence. Upon admission, the resident's diagnoses and history indicated a high risk for substance use and withdrawal, with recommendations for supportive group referrals and possible medication interventions. Despite these identified needs, the facility did not ensure the resident was connected to community support groups, did not develop or sign a behavior contract, and did not provide or assist in obtaining substance use treatment services such as behavioral health support, medication-assisted treatment, or access to support meetings. Documentation revealed that although the care plan included interventions such as monitoring for cravings, room searches for paraphernalia, and working with the resident to identify coping mechanisms, there was no evidence these interventions were actually implemented. The facility also failed to obtain or document physician orders for a monthly injection to reduce substance abuse cravings, despite repeated mentions by the resident's responsible person and care team. Additionally, there was no documentation that the facility staff were trained on recognizing or responding to signs and symptoms of substance abuse, withdrawal, or overdose prior to a critical incident. The lack of implementation and follow-through on the care plan resulted in the resident experiencing a heroin overdose, requiring emergency intervention with Narcan administered by paramedics. The facility did not have an order for the opioid reversal agent, nor did staff administer it as outlined in the care plan. After the overdose, the care plan was not reassessed or updated, and there was no evidence of further action to address the resident's ongoing needs related to substance abuse and dependence.
Failure to Prevent Elopement Due to Inadequate Supervision and Wander Guard Monitoring
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was assessed as an elopement risk and was equipped with a Wander Guard device. The resident, who had diagnoses including schizophrenia and anxiety disorder, demonstrated moderate cognitive impairment and a history of wandering and elopement. The care plan and physician's orders required the Wander Guard to be checked every shift, but documentation showed the last check occurred several days prior to the incident, and staff interviews confirmed that checks were only performed weekly, contrary to the orders and manufacturer’s instructions. On the day of the incident, the resident was discovered missing during a routine check for breakfast, prompting a facility-wide search and notification of law enforcement. The resident was later found offsite and returned by police. Review of facility records indicated that no alarms were triggered by the Wander Guard system at the monitored exits during the time the resident left. Observations and staff interviews revealed that the resident frequently accessed the designated smoking area, which was surrounded by a fence and padlocked gate but lacked a Wander Guard sensor. The resident was observed smoking alone in this area without staff supervision, despite being identified as an elopement risk. Further review of facility policy and manufacturer instructions indicated that the Wander Guard system should be tested daily, with results documented in the medical record. However, the facility’s practice was to test the devices weekly, and the policy did not specify the required frequency. The lack of adherence to the care plan, physician’s orders, and manufacturer’s guidance, combined with insufficient supervision in the smoking area, contributed to the resident’s ability to elope from the facility without detection.
Failure to Perform Daily Testing of Wander Guard System
Penalty
Summary
The facility failed to perform daily functional testing of the Wander Guard system, an alert device worn by residents to prevent unsafe wandering, as required by the manufacturer's instructions. Instead, nursing staff checked the devices weekly, with results documented in the medical record, rather than daily as specified. Interviews with nursing staff and the DON confirmed that seven residents were using the Wander Guard devices and that the facility's policy did not specify a daily testing frequency. Review of the manufacturer's instructions indicated that daily testing and documentation were required, but this was not being followed.
Failure to Provide Timely Pain Management After Admission
Penalty
Summary
A deficiency occurred when a resident admitted for aftercare following joint replacement surgery did not receive appropriate pain management upon admission. The resident, who was cognitively intact and able to communicate, reported that her last dose of pain medication was administered at the hospital prior to admission, and she did not receive any pain medication from the facility until the following day. Nursing documentation confirmed that the resident complained of pain in her left knee, rated as a level 3, but no pain medication was administered on the day of admission, despite physician orders for both acetaminophen and Roxicodone for varying levels of pain. The Medication Administration Record showed no administration of either acetaminophen or Roxicodone on the day of admission, and the first recorded dose was given the next morning, with no documented monitoring of its effectiveness. The DON confirmed that the ordered controlled pain medication was available in the facility's emergency medication supply but was not administered as required. Facility policies reviewed indicated that pain management should be provided according to professional standards and that nurses should obtain needed medications from emergency supplies if unavailable, but these procedures were not followed in this instance.
Failure to Verify Physician Orders for NPO Resident
Penalty
Summary
Staff failed to verify the accuracy of a physician's order for a resident who had a diagnosis of dysphagia following a cerebral infarction and was admitted with a feeding tube. The resident's medical record included a physician's order for NPO (nothing by mouth), yet the Medication Administration Record (MAR) contained orders for oral administration of antibiotics. Licensed nurses documented administration of these medications by mouth over several days. During interviews, the Assistant Director of Nursing confirmed the resident was NPO, and a licensed nurse stated she administered the medications via gastric tube rather than by mouth, but did not clarify the order with the physician. The Director of Nursing acknowledged that the antibiotic orders were written in error and not verified in a timely manner. This resulted in a failure to ensure the accuracy of physician orders and proper maintenance of the resident's medical record.
Restroom Maintenance Deficiency
Penalty
Summary
The facility failed to maintain a restroom in good repair for one of the sampled residents, which compromised the resident's right to a safe, clean, comfortable, and homelike environment. During an observation and interview with the Housekeeping Supervisor and Maintenance Assistant, it was noted that the restroom had peeling paint, an inoperable ceiling fan, a toilet seat partially without its outer coating, and a loose toilet lever. Both staff members confirmed these issues and acknowledged that there were no current work orders in the facility's maintenance system to address them. The facility's policy on Preventative Maintenance, dated August 2014, requires the Maintenance Department to maintain the physical plant in a safe and aesthetically pleasing condition, but this was not adhered to in this instance.
Failure to Implement Care Plan Interventions for Feeding and Pressure Injury Prevention
Penalty
Summary
The facility failed to implement care plan interventions for a resident's feeding assistance needs and pressure injury care and prevention. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, and unspecified glaucoma, required full feeding assistance and had a goal to consume 70-80% of meal intake. However, the Documentation Survey Report (DSR) for December 2024 showed missing meal intake amounts and staff signatures on specific dates, indicating a lack of proper documentation and potentially inadequate feeding assistance. Additionally, the resident had pressure injuries on the heel and sacro coccyx, with care plans indicating the use of pressure redistribution devices. The DSR for December 2024 and January 2025 lacked documentation of the presence of these devices and staff signatures on several shifts, suggesting that the interventions for pressure injury prevention were not consistently implemented. The Director of Nursing acknowledged the missing documentation, which should have been completed if the care was provided.
Improper Positioning of Wound Vacuum Pump
Penalty
Summary
The facility failed to position a wound vacuum pump in accordance with manufacturer guidance for a resident. The order summary report indicated a specific order for the application of a dressing to a wound on the resident's sacrum, which included the use of a Negative Pressure Wound Therapy (NPWT) system. During an observation, the NPWT device's pump was found sitting on the floor next to the resident's bed, with multiple cables and a tube in direct contact with the observer's feet. The manufacturer's guidance specified that the NPWT system and tubing should be positioned to avoid trip hazards and should be level with or below the wound whenever possible. The Director of Nursing agreed that the placement of the wound vacuum on the floor could pose a risk of tripping or disconnection.
Failure to Enforce Hair Restraint Policy in Kitchen
Penalty
Summary
The facility failed to ensure that dietary staff wore appropriate hair restraints during meal service, as required by their policy. Observations on January 15, 2025, revealed that two staff members, identified as [NAME] #4 and [NAME] #5, were not wearing facial hair restraints while preparing and plating meals for residents. The facility's policy, effective February 2024, mandates that hair must be restrained or covered, but it was not adhered to during these observations. Interviews conducted with the involved staff and management highlighted a lack of clarity in the facility's policy regarding the use of facial hair restraints. [NAME] #5 believed that facial restraints were not necessary due to the perceived short length of his facial hair, while [NAME] #4 also did not wear a restraint, citing the facility's lack of requirement. The Dietary Manager admitted that the policy was unclear and stated that facial restraints were only required for facial hair over half an inch in length, although he was unaware of the actual length of the staff's facial hair. The Registered Dietician and the Administrator both confirmed that facial restraints should have been worn in the kitchen.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer their medication, as required by their policy. The policy mandates that residents who wish to self-administer medication must be assessed by a Licensed Nurse, and the assessment must be reviewed by the Interdisciplinary Team (IDT) for approval. The resident in question, who was admitted with a medical history of Parkinson's disease and type 2 diabetes mellitus, had a BIMS score indicating intact cognition. Despite this, there was no evidence in the medical record that the resident had been assessed for self-administration of medication. Observations revealed a bottle of multivitamins on the resident's bedside table, which the resident confirmed they were taking without an assessment or approval from the facility. The resident expressed a desire to continue self-administering their multivitamin. Interviews with facility staff, including an LVN and the DON, confirmed that the resident had not been assessed for self-administration and was not permitted to have the multivitamin in their room. The facility's failure to conduct the required assessment and obtain a physician's order for self-administration led to the deficiency.
Inaccurate MDS Assessment for Resident on Hospice Care
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, leading to a deficiency. The resident, who was admitted with a medical history of neurofibromatosis and was receiving palliative care, had a significant change in status MDS assessment that did not accurately reflect their hospice care status. The MDS indicated a Brief Interview for Mental Status (BIMS) score of 10, showing moderate cognitive impairment, but failed to document the resident's hospice care, despite the care plan and order recap report indicating hospice services were initiated. Interviews with facility staff revealed that the MDS Coordinator acknowledged the oversight and confirmed that the hospice care should have been coded in the MDS. The Director of Nursing emphasized the importance of MDS accuracy for reimbursement and meeting resident needs, while the Administrator highlighted that the MDS triggers quality measures for care planning. The responsibility for ensuring MDS accuracy was attributed to the MDS Coordinator, who admitted the error and the need for a modification to correct the assessment.
Failure to Resubmit Level I PASARR Screening
Penalty
Summary
The facility failed to resubmit a new Level I screening for a resident who remained in the facility beyond 30 days, as required by the preadmission screening and resident review (PASARR) program. The facility's policy, revised in May 2024, mandates that if a resident who was not initially screened remains in the facility longer than 30 days, a Level I screening should be conducted and referred to the appropriate state authority for a Level II PASARR evaluation if necessary. Resident #22, admitted on September 20, 2022, with a medical history of depression and anxiety disorder, did not have a new Level I screening completed after staying in the facility for more than 30 days. Interviews with facility staff revealed a lack of awareness and oversight regarding the requirement for a new Level I screening for Resident #22. The Assistant Director of Nursing was unaware of the need for a new screening, and the Director of Nursing acknowledged that the screening should have been resubmitted after the resident's 31st day in the facility. The Administrator also confirmed that the screening was necessary but was not completed, indicating a lapse in following the facility's policy and state requirements.
Improper Medication Storage for a Resident
Penalty
Summary
The facility failed to ensure proper storage of medications for a resident, leading to a deficiency. Resident #129, who was admitted on 12/31/2024 with a medical history of Parkinson's disease and type 2 diabetes mellitus, was observed to have a bottle of multivitamins on their bedside table on multiple occasions. The resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, and had an order for a multivitamin to be taken once daily. Despite this, the multivitamin was not stored securely as required by facility policy. During observations on 01/14/2025 and 01/15/2025, the surveyor noted the multivitamin bottle on the resident's bedside table. The resident stated they took the multivitamin because it was all-natural and organic. On 01/16/2025, an LVN confirmed the presence of the multivitamin on the bedside table and acknowledged that the resident was not permitted to have it in their room. The facility administrator later stated that medications should be secured in the resident's bedside drawer after assessing the resident's ability to self-administer medication, which was not adhered to in this case.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify the responsible party (RP) after a fall incident involving a resident. The resident, who was admitted with a primary diagnosis of general muscle weakness following a cerebral infarction, had intact cognition and was capable of making healthcare decisions. The resident's niece was designated as the decision maker or RP. On a specific date, the resident experienced an unwitnessed fall while attempting to self-transfer from a wheelchair to a bed, resulting in a skin tear on the right elbow. Although the physician was notified, the RP was not informed of the incident. During interviews and record reviews, it was confirmed that there was no documentation of notification to the RP, despite the facility's policy requiring such communication. The administrator suggested that verbal information might have been relayed to the RP, but this was not documented. The resident's Power of Attorney granted the RP full authority to manage healthcare decisions and receive notifications, emphasizing the importance of informing the RP about incidents affecting the resident's health and safety.
Failure to Assist Resident with Outside Medical Appointment
Penalty
Summary
The facility failed to assist a resident in making an outside appointment for a cataract evaluation as per the prescriber's order. The resident was admitted to the facility and had an order dated 11/1/23 for an evaluation at an ophthalmology clinic. During an interview on 4/15/24, the Administrator confirmed that the facility could not provide documentation showing that staff had attempted to make the appointment before the resident was discharged. The job description for the Social Services Assistant included coordinating and setting up such appointments, and the facility's policy on Resident Rights emphasized the resident's right to access services outside the facility.
Failure to Maintain Accounting System for Resident's Personal Funds
Penalty
Summary
The facility failed to maintain a system for a full and complete accounting and management of personal funds entrusted to the facility for one of the sampled residents. Resident 1, who was admitted with multiple fractures in the right ribs and had intact cognitive abilities, left $300 with the facility's Social Services Assistant (SSA) for purchasing items. However, there was no signed agreement or accounting statement provided to Resident 1 regarding the funds left in the care of the facility. During an observation and interview, it was found that the SSA kept Resident 1's money in a locked safety deposit without any accounting system. The Director of Social Services (DSS) confirmed the absence of a system to account for the cash left by residents. The Administrator also stated that they only have accounting for trust funds but not for cash left by residents. The facility's policy and procedure indicated that a full accounting of all disbursements made to or on behalf of the resident should be maintained, which was not followed in this case.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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