Clearwater Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 1517 East Knickerbocker Drive, Stockton, California 95210
- CMS Provider Number
- 555307
- Inspections on file
- 52
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Clearwater Healthcare Center during CMS and state inspections, most recent first.
A resident with a right lower leg amputation, who primarily used a wheelchair and required at least supervision or touching assist to ambulate short distances with a FWW, was discharged to an independent living facility (ILF) that only accepted fully independent individuals and did not accommodate wheelchair-level care. Facility social services staff informed the ILF that the resident could walk independently up to 150 feet with a walker and did not need a wheelchair, despite ADL, weekly summary, PT, and OT documentation indicating wheelchair-level mobility and assisted ambulation only with therapy. At discharge, ILF staff refused to accept the resident upon realizing he was non-ambulatory, and the resident reported having previously told the social worker he was not ready to leave because he could not walk, resulting in significant distress when he was turned away.
A resident with a traumatic lower-leg amputation who used a wheelchair was transferred to an Independent Living Facility (ILF) after facility staff verbally represented to the ILF that the resident was totally independent and walked with a walker. The ILF, which had only minimal staff and could not provide physical care or assist with ADLs, received no clinical documentation beyond a face sheet and reported that it could not accommodate a wheelchair user. Facility staff later acknowledged there was a miscommunication and that they had not clearly communicated the resident’s ongoing need for a wheelchair, despite a policy requiring that all necessary information and special instructions be shared to ensure a safe and effective transition of care.
A resident with sepsis, acute osteomyelitis, type 2 DM, a PICC line for IV antibiotics, homelessness, and a documented history of meth use was admitted without development of a care plan addressing drug use or elopement risk, despite facility policies requiring a baseline care plan and specific interventions for residents at risk of wandering. The resident asked an RN for a lighter, packed belongings, and left the building unnoticed; later camera review showed the resident exiting the facility gate. The resident remained unaccounted for more than a day, during which family reported he walked a long distance, complained of foot pain, may have attempted to remove his PICC line with scissors, and used drugs. The ADON described an elopement process that included notifying regulatory and protective agencies, but the Administrator acknowledged he did not report the incident to the Department, Ombudsman, or APS as required by facility policy.
A resident admitted with sepsis, acute osteomyelitis, and type 2 DM had a recent methamphetamine use history documented in the acute hospital H&P, but the facility’s admission nursing assessment recorded that the resident had never used drugs. During interviews, the SSD confirmed the resident’s drug use history and acknowledged it had been missed, and the ADON confirmed the discrepancy and stated the responsible nurse completed the assessment incorrectly, noting that staff often rush these assessments. Facility policy and the LVN job description require complete and accurate documentation in the medical record, which was not followed in this case.
A resident with significant mobility and vision impairments was discharged home without confirmation that home health agency (HHA) services were in place, despite orders and recommendations for such services. Facility staff sent referrals but did not verify HHA acceptance before discharge, resulting in the resident being without needed therapy and nursing support at home. The discharge was marked as per resident preference, but therapy and nursing staff indicated it was against medical advice due to ongoing care needs and lack of support.
A resident with significant mobility and mental health needs was unable to use his motorized wheelchair in the facility and requested a transfer to another facility that would accommodate his needs. Despite this request being known to staff, referrals to other SNFs were delayed by about two months, and no follow-up was conducted after the referrals were sent, contrary to facility policy. This resulted in ongoing distress for the resident.
A resident with severe dementia and a history of wandering and behavioral disturbances was placed on 1:1 observation for safety, but was left unattended and entered another resident's room, where they were punched in the chest. Staff and records confirmed that the required continuous supervision was not provided at the time of the incident, leading to physical abuse.
A resident with recent bilateral lower extremity amputations missed a scheduled post-surgical physician appointment because the facility did not provide necessary transportation and Spanish interpretation support. Staff were unable to coordinate a Spanish-speaking staff member or family member to accompany the resident, resulting in a delay in follow-up care for surgical wounds.
A resident with multiple medical conditions did not receive prescribed doses of three medications because the drugs were unavailable or the resident was sleeping. Nursing staff did not follow facility policy to check the e-kit, notify the physician, or document actions taken in the medical record. The pharmacy consultant confirmed that medications should have been accessible through the dispensing machine or e-kit, but required notifications and documentation were not completed.
Multiple residents requiring assistance with mobility and toileting experienced significant delays in call light response, with some waiting up to 30 minutes for staff to provide help. Observations and interviews confirmed that staff did not consistently respond promptly, despite facility policy and expectations for timely assistance.
Two residents with significant mobility impairments missed or were late to scheduled medical appointments due to the facility's failure to arrange timely transportation and communicate appointment schedules among staff. Miscommunication and lack of awareness among nursing staff contributed to these deficiencies.
A resident with muscle weakness and paraplegia was denied readmission after being cleared for return from a hospital, following a facility-initiated transfer due to alcohol intoxication. Despite not signing an AMA form and being cleared by the hospital, the facility refused readmission, resulting in the resident's temporary loss of residence and emotional distress.
A resident transferred to a hospital was not provided with written notice of bed hold, transfer, or discharge, nor was the required notification sent to the Ombudsman. The facility did not issue these documents at the time of transfer, despite policy and regulatory requirements, resulting in the resident not being fully informed of their rights and experiencing emotional distress due to a prolonged hospital stay and temporary loss of residence.
A resident with multiple medical and mental health conditions was scheduled for discharge after skilled services ended, but neither the resident, her representative, nor the Ombudsman received the required written discharge notice. Instead, discharge information was communicated verbally, and the lack of formal notice led to confusion, anxiety, and a delayed appeal process. The facility's failure to provide written notification violated regulations and policy regarding discharge procedures and residents' rights.
Four residents with significant mobility impairments and at risk for pressure ulcers did not receive repositioning every two hours as required by their care plans. Staff interviews and record reviews confirmed that these residents were dependent on staff for turning, but documentation showed missed or delayed repositioning events. The DON verified that the care plan interventions were not consistently implemented or documented according to facility policy.
A resident with frequent yelling behavior, who is mostly non-verbal and unable to use the call light, was verbally threatened and physically confronted by her roommate, who was on hospice care and agitated by the noise. Staff and care plans failed to provide individualized interventions or effective monitoring, resulting in the resident experiencing fear and distress.
A live baby cockroach was observed on a clean colander in the kitchen, and multiple kitchen items were found with brownish residues, indicating inadequate cleaning. The Food Services Director confirmed the pest sighting and the process for reporting it, while the Registered Dietitian and Maintenance Director described the pest control service schedule. Facility policies required routine cleaning and monthly pest control, but these were not effectively implemented.
Surveyors found that food items in the kitchen, including frozen foods and spices, were not properly labeled or dated, and some were expired. Cooking equipment and utensils, such as pots, pans, a toaster oven, and stove grates, were observed with visible residues and discoloration, despite facility policies requiring regular cleaning and sanitation. The Food Services Director acknowledged these issues as food safety risks, and these failures had the potential to impact all residents receiving facility-prepared meals.
Staff who declined the flu vaccine did not wear required masks, a resident on airborne precautions for COVID-19 had their room door left open against policy, and hand hygiene was not performed or offered to residents during meal service. These actions were contrary to facility policy and CDC guidelines, as confirmed by interviews and record review.
Two residents with urinary catheters were observed with uncovered catheter drainage bags, despite facility policy and staff acknowledgment that dignity bag covers should be used to protect privacy. Both a nurse and the DON confirmed that catheter bags should be covered at all times to maintain resident dignity and prevent emotional distress.
A resident who was responsible for their own care and required surgical aftercare was not informed of a scheduled follow-up appointment with a cardiothoracic surgeon, resulting in a missed appointment. Facility staff confirmed the appointment was documented but not communicated to the resident, contrary to policy.
A resident's representative did not receive the required Notice of Medicare Non-Coverage (NOMNC) before skilled nursing services ended. The NOMNC was sent by regular mail without verification, no follow-up was made, and the address used was incorrect. As a result, the resident and representative were not informed of the end of Medicare coverage or their appeal rights.
A resident admitted with dementia, psychosis, and anxiety disorder did not receive a required PASRR Level II evaluation after a positive Level I screening for serious mental illness. Despite state notification and multiple attempts to arrange the evaluation, facility staff did not respond or ensure the process was completed, with interviews revealing confusion over staff responsibilities and a lack of adherence to facility policy.
Two residents with significant mobility and self-care deficits did not receive scheduled showers as required, with records and staff interviews confirming missed showers and lack of documentation. Both residents required substantial assistance with bathing, and the facility's policy for hygiene and skin assessment was not followed.
A resident with a recent periprosthetic knee fracture and a care plan for pain management experienced severe pain for approximately two hours without assessment or administration of ordered pain medication. Despite repeated requests and staff notifications, the resident's pain was not addressed in a timely manner, even though the medication was available in the emergency kit.
A resident did not receive their scheduled morning medications, which included treatments for hypertension, pain, depression, and respiratory conditions, until after noon, despite repeated requests. Staff confirmed that the medications were due earlier in the morning but were administered late, resulting in some noon medications being missed. The DON verified that this late administration was outside facility policy and contradicted physician orders.
Surveyors found that two medication carts contained opened medications without opened-on dates, an opened probiotic that required refrigeration but was not stored properly, a hazardous medication not kept in a protective bag, and a resident's rings stored in a medication cart drawer. LNs and the DON confirmed these practices did not follow facility policy and proper medication storage protocols.
The facility did not follow prescribed portion sizes for yams and vegetables and served roast beef with blackened edges during a lunch meal, affecting 107 residents. Despite posted guides and in-services, staff used incorrect scoop sizes and did not remove overcooked portions, resulting in meals that did not meet menu specifications for various prescribed diets.
A resident in an LTC facility received duplicate blood thinner medications for 3.5 days due to a clerical error in the electronic health record system. The concurrent administration of Rivaroxaban and Dabigatran was not clarified with the medical doctor, resulting in critically high PT/INR levels. The resident suffered severe complications, including internal bleeding and cardiogenic shock, leading to their death. The facility's medication administration and communication policies were not adequately followed.
A facility failed to administer medications on time for three residents, including a resident with Parkinsonism who experienced delays in receiving critical medications, leading to increased tremors. Another resident with diabetes and heart failure received medications late, risking blood glucose fluctuations and inconsistent blood pressure control. Additionally, a resident's constipation was not addressed promptly, and incorrect identification photos were used, risking treatment errors.
A facility failed to maintain resident confidentiality when medication for a resident with hypertension was mistakenly sent home with another resident. The DON confirmed the error, highlighting a risk of incorrect medication use and a HIPAA compliance issue. The facility's LVN job description stresses the importance of maintaining confidentiality.
A resident with chronic respiratory failure, muscle weakness, and morbid obesity was discharged from an LTC facility without adequate preparation for her home environment, leading to her readmission to the hospital. The discharge was marked as planned, but there was confusion about whether it was against medical advice. The facility failed to ensure a safe transition of care, and Adult Protective Services noted the discharge was unsafe.
A resident with a history of inappropriate behavior inappropriately touched two other residents in a LTC facility. Despite being aware of the resident's behavior, the facility's monitoring was inadequate, with incomplete documentation and lapses in supervision. The facility's policy on abuse prevention was not effectively implemented, leading to repeated incidents.
Failure to Coordinate Safe Discharge for Non-Ambulatory Resident to Independent Living Setting
Penalty
Summary
The deficiency involves the facility’s failure to complete a safe and coordinated discharge for a resident with a right lower leg traumatic amputation who required a wheelchair for primary mobility. The resident was admitted with a diagnosis of complete traumatic amputation between the knee and ankle and, according to ADL documentation from late March through the discharge date, used a wheelchair for locomotion in the room and facility on every shift except one. A weekly summary completed the day before discharge documented that the resident used a wheelchair most of the day and did not ambulate with a walker, cane, or crutches. Despite this, the resident was discharged to an Independent Living Facility (ILF) that only accepted individuals who were completely independent and did not require hands-on assistance or wheelchair-level care. Prior to discharge, the facility’s social worker communicated to the ILF agency manager that the resident could walk independently up to 150 feet with a front wheeled walker and did not need a wheelchair for mobility. The ILF manager reported that this information was the basis for accepting the resident, as the ILF did not have staff to provide hands-on assistance. In contrast, a CNA stated she had never seen the resident walk and that he needed a wheelchair to get around the facility. The facility transporter also reported that upon arrival at the ILF, staff questioned whether the resident could walk, and he informed them that the resident had an amputated leg and did not walk, at which point ILF staff stated they had accepted the resident because they were told he was independent and could walk but could not accept him in a wheelchair. Therapy documentation and interviews further showed that the resident’s safe mobility needs were not accurately conveyed in the discharge process. The PT discharge summary indicated the resident required supervision or touching assistance to ambulate with a front wheeled walker and was not walking independently in the facility except with therapy staff. The OT discharge summary documented that the resident was modified independent at wheelchair level and could hop up to 150 feet with a front wheeled walker only with stand-by assist, with the OT clarifying that the recommended device for functional mobility was a wheelchair until a prosthesis was obtained. The resident reported telling the social worker weeks before discharge that he was not ready to leave because he was unable to walk, and described being told at the ILF to be taken back because he was in a wheelchair and had one leg, which caused him to feel very upset and to feel that nobody wanted him. The social services assistant stated that, for ILF transfers, the facility only provided a face sheet and that she believed the resident walked on his own with a front wheeled walker, indicating that a comprehensive, individualized discharge summary and evaluation of discharge needs, as required by facility policy, was not communicated to the receiving ILF.
Failure to Communicate Care Needs During Transfer to Independent Living Facility
Penalty
Summary
The facility failed to ensure appropriate transfer and discharge information was communicated to a receiving provider, resulting in a resident being sent to an Independent Living Facility (ILF) that could not meet his needs. The resident had been admitted with a diagnosis that included a complete traumatic amputation of the right lower leg between the knee and ankle and used a wheelchair. According to the resident’s family member, when the resident arrived at the ILF, staff there stated they could not meet his needs because he was in a wheelchair. The family member reported that the ILF had been informed by the facility that the resident was independent in his care needs and walked with a walker, and that the resident called her to pick him up, crying and stating that nobody wanted him. The ILF agency manager stated that the facility did not send any documentation for the resident and had verbally assured him that the resident was totally independent. The manager explained that ILF staff could not assist with care needs such as showers, transfers in and out of bed, or any physical care, and that staff consisted only of a cook, the owner, and the manager. The facility’s Social Services Assistant reported that when residents transferred to an ILF, the only information provided was the face sheet with demographics, contacts, and diagnoses. The Case Manager Assistant stated that after the discharge, the ILF administrator told her they could not accommodate a resident in a wheelchair, and acknowledged there was a miscommunication and that the facility should have conveyed that the resident used and would continue to require a wheelchair. A review of the facility’s “Transfer or Discharge Documentation” policy indicated that details of transfers or discharges and all special instructions and necessary information for a safe and effective transition of care were to be communicated to the receiving facility or provider.
Failure to Care Plan and Supervise Resident With Drug Use History, Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at risk for wandering and elopement received adequate supervision and an appropriate care plan addressing known drug use. The resident was admitted in January 2026 with diagnoses including sepsis, acute osteomyelitis of the right ankle and foot, and type 2 diabetes mellitus, and had a PICC line in place for IV antibiotics. The acute hospital H&P dated 1/15/26 documented a recent history of methamphetamine use. The Social Services Director and the ADON both confirmed that, despite this known history, no care plan was developed to address the resident’s drug use, and no psychiatric consultation was obtained. Facility policies required a baseline care plan within 48 hours of admission and specified that residents identified as at risk for wandering or elopement must have care plan strategies and interventions to maintain safety. On the early morning of 1/25/26, a licensed nurse reported that the resident requested a lighter to smoke cigarettes during the medication pass. When told a lighter was not available, the resident began packing his belongings while the nurse continued the medication pass. At approximately 5:15 a.m., the nurse returned to the resident’s room and found the resident was no longer there. The nurse searched the building but could not locate the resident and then reported the missing resident to the ADON and another nurse. Subsequent review of facility camera footage by another licensed nurse showed the resident exiting the facility’s outside gate at 4:57 a.m. without staff awareness. Family later reported that the resident, who was known to be homeless with a long history of drug use, walked a long distance to a family member’s home, complained of foot pain, had scissors and was possibly attempting to remove the PICC line, and had used drugs after leaving the facility. The resident was unaccounted for approximately 27 hours and 30 minutes and was later at a local hospital. The ADON stated that the facility’s elopement process included contacting the Department, police, Ombudsman, and other key personnel, and acknowledged concern for the resident’s safety given the unsafe neighborhood, time of day, weather, PICC line, and drug use history. The Administrator confirmed he did not contact the Department, Ombudsman, or Adult Protective Services after the resident left, despite facility policy requiring reporting of unusual occurrences that affect the health, safety, or welfare of residents to appropriate agencies within specified time frames.
Inaccurate Documentation of Substance Use History on Admission Assessment
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for one of two sampled residents when the substance use history section of the admission nursing assessment was inaccurately documented. The resident was admitted in January 2026 with diagnoses including sepsis, acute osteomyelitis of the right ankle and foot, and type 2 diabetes mellitus. The acute hospital history and physical dated 1/15/26 documented a history of recent methamphetamine use. However, the facility’s admission nursing assessment dated 1/16/26 indicated under the substance use history section that the resident had never used drugs, creating conflicting information between the hospital record and the facility’s assessment. During interviews and concurrent record reviews, the Social Services Director confirmed that the resident had a history of drug use and acknowledged that this information had been missed when reviewing the record. The Social Services Director stated that a care plan and psychiatric consultation were not completed for the resident. The Assistant Director of Nursing confirmed the discrepancy between the hospital H&P and the admission nursing assessment and stated that the licensed nurse responsible for the admission assessment documented it incorrectly. The ADON further stated that staff often complete these assessments incorrectly because they are rushing. Review of facility policy indicated that documentation in the medical record is required to be objective, complete, and accurate, and the LVN job description requires maintaining accurate and up-to-date medical records, including nursing assessments and care plans.
Failure to Ensure Safe Discharge with Home Health Services Established
Penalty
Summary
A deficiency occurred when a resident was discharged home without ensuring that home health agency (HHA) services were established, despite orders and recommendations for such services. The resident, who was admitted for rehabilitation following a displaced left femur fracture and had generalized muscle weakness and legal blindness, was discharged home at her own request. The discharge orders included the need for physical therapy, occupational therapy, registered nurse services, and durable medical equipment, with the expectation that these would be provided through HHA. However, the facility failed to confirm that the HHA could initiate services prior to discharge. Interviews and record reviews revealed that the social services department sent referrals for HHA and necessary equipment, but only learned after discharge that the HHA could not accept the resident due to her not being established with a primary care physician. Multiple staff members, including the case manager, assistant director of nursing, and director of therapy, confirmed that HHA services should have been verified and established before discharge, especially given the resident's high risk factors such as living alone, impaired mobility, and vision loss. The resident's emergency contact also expressed concerns about her safety at home without adequate support. Documentation showed that the discharge was marked as being per the resident's preference, but therapy and nursing staff indicated that the discharge was against medical advice due to the resident's ongoing need for supervision and therapy. The lack of established HHA services resulted in a gap in care and placed the resident at risk, as confirmed by staff interviews and progress notes. The facility did not document the discharge as being against medical advice, nor did it ensure that the interdisciplinary team was fully informed of the lack of HHA services prior to discharge.
Failure to Provide Timely Social Services Support for Resident Transfer Request
Penalty
Summary
The facility failed to provide timely and appropriate social services support for a resident who wished to leave the facility due to being unable to use his motorized wheelchair. The resident, who had a history of generalized muscle weakness, major depressive disorder, an amputation below the knee, and multiple sclerosis, expressed his desire to transfer to another facility that would accommodate his motorized wheelchair approximately one month after admission. Despite this, referrals to alternative facilities were not sent until about three months after his initial request, and there was no documented follow-up by staff to check on the status of these referrals. Interviews with facility staff revealed that the resident's request to transfer was known to the social services department, but the Case Manager Assistant did not document the request in the medical record. The Business Office Assistant sent referrals to three other skilled nursing facilities at the resident's request, but received no responses and did not follow up, as this responsibility was assigned to the social services department. The Social Services Assistant confirmed that no follow-up was conducted after the referrals were sent, despite facility policy indicating that follow-up should occur within a few days. Facility policies and job descriptions reviewed indicated that the social services department was responsible for discharge planning, including making referrals and following up to ensure residents' needs and preferences were met. The failure to act in a timely manner and to follow up on the resident's transfer request resulted in the resident experiencing stress and anxiety due to being unable to use his motorized wheelchair, which was essential for his mobility and psychosocial well-being.
Failure to Maintain 1:1 Supervision Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with unspecified dementia and severe cognitive impairment was placed on continuous one-to-one (1:1) observation due to behaviors such as wandering, entering other residents' rooms, hitting staff, and attempting to leave the facility. The care plan and staff interviews confirmed that the expectation was for a staff member to be with the resident at all times to ensure safety and prevent incidents. Despite these interventions, the resident was left unattended and wandered into another resident's room. During this time, another resident became agitated and punched the resident in the chest. Multiple staff members, including CNAs and nurses, confirmed that the resident on 1:1 observation did not have a staff member present at the time of the incident, which was contrary to facility policy and the resident's care plan. Facility records and staff interviews indicated that the 1:1 observation was implemented specifically to prevent such incidents, and that staff were aware of the procedures requiring continuous supervision. The failure to maintain 1:1 supervision resulted in the resident being physically abused by another resident, as documented in care plans, progress notes, and staff statements.
Missed Post-Surgical Appointment Due to Lack of Transportation and Interpreter Coordination
Penalty
Summary
The facility failed to ensure that a resident with bilateral below-the-knee amputations received necessary assistance with transportation and interpretation services to attend a scheduled post-surgical physician appointment. The resident, who had recently undergone amputation and required follow-up care for surgical wounds, missed her appointment because no staff member was available to accompany her and provide Spanish interpretation, as required for her to communicate effectively during the visit. The facility attempted to contact the resident's family to provide interpretation, but the responsible party was unable to assist due to language barriers. Interviews with facility staff revealed that the process for arranging transportation and interpretation was not effectively coordinated. The receptionist received the order to schedule the appointment and was informed of the need for a Spanish-speaking staff member to accompany the resident. However, due to staffing shortages on the day of the appointment, no staff member was available to go with the resident. The nursing and administrative staff indicated that they expected either a staff member or a family member to accompany the resident, but this was not arranged in time for the appointment. The facility's policy on language access states that individuals with limited English proficiency must have meaningful access to services, and that family members should not be relied upon for interpretation unless explicitly requested by the resident. Despite this, the facility's actions did not ensure that the resident had access to interpretation services for her medical appointment, resulting in the missed appointment and a delay in post-surgical care.
Failure to Administer Medications as Ordered and Inadequate Documentation
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one resident, resulting in missed doses of three prescribed medications. The resident, who had a history of a displaced intertrochanteric fracture of the right femur and hypertension, was admitted with orders for Amlodipine for hypertension, Famotidine for GERD, and Linzess for irritable bowel syndrome. On the date in question, documentation showed that the 9 a.m. doses of Amlodipine and Linzess were not administered due to the medications being unavailable, and the 6 a.m. dose of Famotidine was not given because the resident was sleeping. Interviews with nursing staff revealed that the standard procedure when a medication is unavailable is to check the emergency kit (e-kit) and, if not found, notify the physician and document the actions taken in the resident's progress notes. However, review of the resident's electronic medical record showed no documentation that the physician or pharmacy was notified about the missed doses, nor was there any record of follow-up actions or communication regarding the unavailability of the medications. The nurse supervisor confirmed that the facility's policy was not followed in this instance. The pharmacy consultant confirmed that the facility had a new medication dispensing machine and that medications should be accessed from this machine first, with the e-kit as a backup. Despite these resources, the medications were not administered as ordered, and required notifications and documentation were not completed. Facility policy required medications to be administered in a timely manner and within one hour of the prescribed time, which was not adhered to in this case.
Delayed Call Light Response for Residents Needing Assistance
Penalty
Summary
The facility failed to ensure that residents' needs were accommodated by not responding to call lights in a timely manner for at least two of four sampled residents. Observations and interviews revealed that one resident waited an extended period for assistance with changing an incontinent brief and for help moving from bed, with a call light remaining unanswered for at least 27 minutes. The resident's care plan indicated a need for substantial assistance with activities of daily living due to weakness and impaired mobility. Another resident reported waiting up to 30 minutes for staff to respond to call lights, and was observed with a call light on for 12 minutes before staff responded. This resident also required assistance with toileting and used an incontinent brief due to generalized muscle weakness and mobility issues. Additional interviews with other residents confirmed similar delays, with one resident stating the longest wait was 20 minutes and that response times were longer during the evening shift. The Assistant Director of Nursing stated that the expectation was for call lights to be answered within 1-2 minutes, or at least less than 5 minutes, and acknowledged that waits of 15 minutes or more were too long. Facility policy required prompt response to call lights by all staff, regardless of assignment. These findings demonstrate that the facility did not consistently meet its own standards or residents' needs for timely assistance.
Failure to Arrange Timely Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure transportation was properly arranged for two residents, resulting in missed or delayed medical appointments. One resident, with a history of hemiplegia and generalized muscle weakness, missed a scheduled primary care appointment because transportation was not arranged in a timely manner. The receptionist was only notified of the appointment on the day it was scheduled, and when transportation arrived, the resident was not ready. The charge nurse assigned to the resident was unaware of the appointment, and the facility's progress notes indicated that transportation was servicing another resident at the time, necessitating a reschedule. Another resident, diagnosed with a left tibia fracture, foot sprain, and generalized muscle weakness, arrived late to an orthopedic appointment due to delayed facility-owned transportation and was unable to be seen by the physician. The resident reported feeling unimportant due to the lack of prioritization for her scheduled pick-up. Staff interviews revealed miscommunication and lack of awareness among nurses and CNAs regarding residents' appointments, contributing to the missed and delayed appointments.
Failure to Readmit Resident After Hospital Clearance
Penalty
Summary
The facility failed to ensure that a resident, who had diagnoses including generalized muscle weakness and paraplegia, was readmitted after being cleared for return from a general acute care hospital. The resident had left the facility without notifying staff, returned the same day, and was subsequently sent to the hospital due to alcohol intoxication. Despite being cleared by the hospital for return, the facility denied readmission, citing the resident's altered mental status and considering the situation as an 'Against Medical Advice' (AMA) discharge, even though the resident did not sign an AMA form. Interviews with facility staff revealed inconsistent application of AMA procedures and a lack of clear documentation regarding the resident's discharge status. The resident remained at the hospital after being denied readmission, resulting in a temporary loss of residence and reported emotional distress. Facility records and staff interviews confirmed that the discharge was initiated by the facility after the resident returned intoxicated, and that the facility's policy allows for return after emergency hospital transfers unless a facility-initiated discharge is warranted. The facility's actions did not align with their own policy, as the resident was not permitted to return despite being cleared by the hospital and not having formally left AMA.
Failure to Provide Required Transfer, Discharge, and Bed Hold Notices
Penalty
Summary
The facility failed to provide required documentation and notifications related to a resident's transfer to a General Acute Care Hospital (GACH). Specifically, the facility did not issue a written notice of bed hold to the resident at the time of transfer, despite the policy requiring such notice both at admission and at the time of transfer or within 24 hours if the transfer was emergent. Although the resident had previously declined a bed hold during admission, the facility did not provide the required written notice at the time of the hospital transfer, as confirmed by both the DON and the Administrator during record reviews and interviews. Additionally, the resident was not given a written notice of transfer or discharge in a manner that could be understood, nor was the required notice sent to the Ombudsman’s office. The facility staff considered the transfer to be facility-initiated due to the resident's condition at the time of transfer, but did not provide the necessary documentation or notifications. The DON and Administrator both confirmed that the notice of transfer or discharge was not issued to the resident or the Ombudsman, contrary to facility policy and regulatory requirements. As a result of these failures, the resident was not fully informed of their rights regarding bed hold, return to the facility, or the right to appeal the discharge. The lack of notification and documentation led to the resident experiencing a prolonged stay in the hospital emergency room and a temporary loss of residence, which resulted in emotional distress for the resident.
Failure to Provide Required Written Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide a required written discharge notice to a resident, the resident's representative, and the Office of the Long-Term Care Ombudsman prior to a planned discharge. The resident, who had a history of cerebral infarction, muscle weakness, gait abnormalities, dysphagia, major depressive disorder, and anxiety disorder, was scheduled for discharge to home with support following the cessation of skilled services. Although the discharge disposition was discussed verbally with the resident's daughter and referrals for post-discharge support were made, no formal written notice of discharge was given to the resident, her representative, or the Ombudsman as required by regulation. Interviews revealed that the Social Services Director acknowledged the lack of a formal discharge notice, stating that it was not provided because the discharge was still pending. Both the resident and her family member confirmed that they were verbally informed of the impending discharge about a week in advance, but did not receive the required written notice. The family member appealed the discharge, and the Ombudsman was involved after being contacted by the family. The Ombudsman also confirmed that no written notice was received and that the resident was anxious due to the discharge process and lack of communication. Facility policy requires documentation of transfer or discharge and communication with the receiving provider, as well as preparation of the resident in advance. Federal and state regulations mandate that written notice be provided to the resident, their representative, and the Ombudsman at least 30 days in advance, or as soon as practicable, with an opportunity to appeal. In this case, the absence of a written notice removed the opportunity for timely advocacy and appeal, and resulted in confusion and distress for the resident and her family.
Failure to Implement and Document Repositioning Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement and document the required repositioning interventions for four residents who were assessed as being at risk for pressure ulcer development. Each of these residents had significant mobility impairments, such as hemiplegia, anoxic brain damage, paraplegia, or other abnormalities of gait and mobility, and were dependent on staff for turning and repositioning in bed. Their care plans specifically included interventions for turning and repositioning every two hours and as needed, in accordance with facility policy and recognized standards of practice. Observations and interviews with staff confirmed that these residents were unable to reposition themselves and relied entirely on staff for this care. However, a review of the electronic health records and point of care documentation for a specific date revealed significant gaps in the documentation of turning and repositioning. For each of the four residents, the documented times for repositioning did not meet the care plan requirement of every two hours, with long intervals between recorded repositioning events. The Director of Nursing confirmed that the documentation did not show that the residents were turned and repositioned as frequently as required by their care plans. The facility's own policies require that residents who are bed-bound and dependent on staff be repositioned at least every two hours, and that care plans be implemented as written to address identified risks. The lack of documented evidence that these interventions were carried out as planned constituted a failure to implement the care plans and facility policy, potentially exposing the residents to the risk of pressure ulcer development.
Failure to Protect Resident from Verbal Threats and Aggression by Roommate
Penalty
Summary
The facility failed to implement individualized and effective interventions to protect a resident with known yelling behavior from verbal threats and physical aggression by her roommate. On the evening of the incident, a certified nursing assistant (CNA) heard the resident screaming in a manner that was described as frightened and different from her usual vocalizations. Upon entering the room, the CNA observed the roommate standing over the resident, holding her down by the shoulder with a fist raised to her face, and verbally threatening to hit her if she did not stop yelling. The resident was visibly frightened, with a surprised look on her face, and became quiet after the intervention of the CNA. Multiple staff interviews and observations confirmed that the resident who was threatened is mostly non-verbal, calls out frequently as a means of communication, and does not understand how to use the call light. Staff reported that her calling out is her baseline behavior and that she is unable to express her needs verbally. The roommate who made the threats was on hospice care and had a history of room changes, some of which were related to roommate issues, but there was no clear documentation of previous aggressive incidents involving other residents. The roommate admitted to being agitated by the yelling and confirmed that she threatened and physically confronted the resident. A review of care plans and facility policies revealed that the interventions in place for the resident with yelling behavior were not sufficiently individualized or effective in preventing the incident. The care plan included general interventions such as explaining procedures and discussing behaviors, but did not address the specific risks associated with her communication style or the potential for conflict with roommates. Documentation and behavior monitoring for both residents were found to be lacking or incomplete, and staff did not consistently respond to the resident's calls for assistance. The facility's failure to implement and update appropriate interventions resulted in the resident experiencing fear and potential psychosocial distress.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
A deficiency was identified when a live baby cockroach was observed crawling on a clean colander on a shelf next to the stove in the kitchen, where meals were prepared for 107 residents. During the same inspection, multiple pieces of kitchen equipment, including a pot on the stove, a flat pan, a frying pan, and a toaster oven, were found with brownish, gummy, or flaky substances, indicating inadequate cleaning. These findings were confirmed by the Food Services Director (FD) during concurrent observation and interview. The FD acknowledged the presence of the cockroach and stated that the process was to report pest sightings to Maintenance, noting the risk to food safety. The Registered Dietitian (RD) confirmed that the facility was addressing the cockroach issue and that two pest control companies serviced the facility, one monthly and the other every two weeks. The Maintenance Director confirmed the pest control service schedule. Facility policies reviewed indicated that routine cleaning and pest control procedures should be followed, and that monthly pest control inspections and services were required, with additional servicing as needed.
Deficient Food Storage, Preparation, and Equipment Sanitation
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and equipment sanitation practices. In the walk-in freezer, there were open and unlabeled boxes of frozen chicken patties, whole kernel corn, green peas, and green leaf spinach. Additionally, an opened container of seasoning salt with an expired date was found in the dry storage area, and the Food Services Director (FD) confirmed uncertainty about whether the date was an expiration or opened date. These issues were acknowledged by the FD as food safety risks. Further inspection of the kitchen revealed that a large pot being used to prepare resident meals had a thick, brownish gummy substance on its bottom and sides. A flat pan and a frying pan, both stored with clean pots and pans, were found with caked and flaky brownish substances on their inner edges. The toaster oven next to the stove had a brownish substance on its shelves, and the stove top grates showed grayish discoloration. The FD confirmed that these conditions posed food safety risks and stated that the stove was only cleaned monthly. A review of the facility's policies and procedures indicated requirements for labeling and dating all food items, proper storage of dry and frozen foods, and regular cleaning of kitchen equipment and utensils. The facility's practices did not align with these policies or with the US FDA Food Code, which requires food-contact and nonfood-contact surfaces to be kept clean and free of residue. These failures had the potential to affect all 107 residents who received facility-prepared meals.
Failure to Adhere to Infection Prevention and Control Protocols
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for its census of 115 residents. Two unvaccinated staff members, the assistant director of staff development and the receptionist, were observed walking inside the facility without wearing masks, despite having declined the influenza vaccine for the 2024/2025 season. Facility policy, as well as CDC guidance, required unvaccinated staff to wear masks during flu season, and both the infection preventionist and director of nursing confirmed that this was a mandated practice to prevent the spread of influenza to residents and staff. A resident with a recent admission diagnosis of COVID-19 was placed on airborne precautions, with medical orders and care plans specifying that the room door should remain closed. However, multiple observations confirmed that the resident's door was left open on several occasions because the resident was yelling and did not want the door closed. Staff, including CNAs and licensed nurses, acknowledged that the door should be closed for airborne isolation, and that leaving it open increased the risk of spreading infection. The facility's own policies and CDC recommendations were not followed, as the door remained open without alternative containment measures consistently in place. Additionally, during a lunch tray pass, the assistant director of nursing was observed delivering meal trays to residents without offering them hand hygiene opportunities or performing hand hygiene between residents. The ADON admitted to not knowing what to offer residents for hand cleaning and did not use hand sanitizer herself during the process. The director of nursing confirmed that facility policy required staff to perform hand hygiene and offer it to residents before meals, and acknowledged that this protocol was not followed during the observed tray pass.
Failure to Cover Urinary Catheter Bags Compromises Resident Dignity and Privacy
Penalty
Summary
Two residents with urinary catheters were not provided with dignity bag covers for their catheter drainage bags, resulting in a failure to protect their privacy and dignity. One resident, who had paraplegia and neuromuscular dysfunction of the bladder, was observed lying in bed with an uncovered catheter bag and expressed a preference for the bag to be covered. A licensed nurse confirmed the lack of a cover and acknowledged that catheter bags should be covered to maintain privacy and dignity. Another resident, diagnosed with benign prostatic hyperplasia and chronic kidney disease, was also observed with an uncovered catheter bag while lying in bed. The same licensed nurse confirmed this observation and stated that the absence of a cover could cause emotional distress and violate the resident's privacy. The Director of Nursing further confirmed that catheter bags should always be covered to protect residents' privacy, as outlined in the facility's policy on dignity.
Resident Not Informed of Post-Surgery Follow-Up Appointment
Penalty
Summary
A deficiency occurred when a resident, who was admitted with a diagnosis requiring surgical aftercare following circulatory system surgery and was his own responsible party, was not informed about a scheduled post-surgery follow-up appointment with a cardiothoracic surgeon. The hospital discharge summary included instructions for this follow-up, and the appointment was documented in the facility's records. However, the resident stated he was not told about the appointment and therefore missed it. The outside medical office confirmed the resident was a no-show, and the appointment had to be rescheduled. Interviews with facility staff, including the Appointments, Scheduling and Transportation Coordinator (ASTC) and the Director of Nursing (DON), confirmed that the appointment was noted in the discharge orders and that the facility had a process for tracking appointments. Despite this, the resident was not consulted or informed about the appointment, as required by facility policy. The ASTC acknowledged the failure to notify the resident, which led to the missed appointment.
Failure to Properly Deliver Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure that a Notice of Medicare Non-Coverage (NOMNC) was properly delivered to a resident or her representative prior to the termination of Medicare-covered skilled nursing services. The resident, who was her own responsible party, had opted for her representative to receive and sign the NOMNC form. The case manager mailed the NOMNC form to the representative using standard mail, did not use certified mail or any method that could verify delivery, and did not follow up to confirm receipt. The NOMNC form was not signed by the resident or her representative, and no follow-up call was made to ensure the notice was received. During an interview, the resident's representative stated she never received the NOMNC form or any phone call from the facility regarding the Medicare notice. Additionally, the mailing address used by the facility was incorrect, as indicated on the Medicare Attestation Form. Facility policy and CMS instructions require that residents or their representatives be informed in advance of changes to their bills and that the NOMNC be delivered in a manner that provides signed verification of delivery. In this case, the facility did not meet these requirements, resulting in the resident and her representative not being informed of the end of coverage or their appeal rights.
Failure to Complete Required PASRR Level II Evaluation After Positive Screening
Penalty
Summary
The facility failed to complete the required Pre-Admission Screening and Resident Review (PASRR) Level II evaluation for a resident who had a positive Level I screening for serious mental illness (SMI). The resident was admitted with diagnoses including dementia, psychosis, and anxiety disorder. Documentation from the California Department of Health Care Services indicated that a Level II evaluation was required, but the evaluation was not completed due to unresponsiveness from facility staff to multiple attempts at communication by the state. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for ensuring the PASRR Level II evaluation was scheduled and completed. The Social Services Director confirmed that the process was expected to be completed as part of admissions, but had not personally handled it. The Admissions Coordinator, Business Office Manager, and MDS Coordinator each described different understandings of their roles in the PASRR process, with none taking ownership of the follow-up required after a positive Level I screening. The facility's own policy stated that new admissions with possible mental disorders, intellectual disabilities, or related conditions should be referred for Level II evaluation, with the social worker responsible for making referrals to the state authority. Despite this, the required evaluation was not completed for the resident, and staff interviews confirmed that the process was not followed as outlined in facility policy.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers to two residents who were unable to perform activities of daily living independently. One resident, admitted with multiple fractures, generalized muscle weakness, and mobility issues, did not receive any showers since admission, despite being scheduled for showers twice weekly. This was confirmed by both the resident and facility staff, who acknowledged that the resident had missed scheduled showers and that there was no documentation of showers being provided. Another resident, admitted with hemiplegia, muscle weakness, and impaired mobility, also did not receive scheduled showers as required. The resident reported only receiving one shower since admission and was unaware of her shower schedule. Review of records and interviews with staff confirmed that scheduled showers were missed, and the resident required substantial to maximal assistance with bathing. Facility policy required documentation of showers and skin assessments, but records indicated these were not completed as scheduled for the affected residents.
Failure to Provide Timely Pain Management for Resident with Acute Pain
Penalty
Summary
A deficiency occurred when a resident with a history of a periprosthetic fracture around the right knee joint, following an assault and subsequent surgical repair (ORIF), experienced unmanaged pain. The resident's care plan identified a risk for acute and chronic pain and directed staff to anticipate and respond immediately to pain complaints, including administering medication as ordered. Despite these directives, the resident reported severe pain (10/10) and had been requesting pain medication since 3:00 PM. Observations confirmed the resident was in visible distress, and the call light was used multiple times to request assistance. Certified nursing staff (CNA) reported notifying the licensed nurse (LN) three times about the resident's pain, but the LN had not assessed the resident or administered pain medication, citing that the ordered Norco had not yet been delivered by the pharmacy. The Assistant Director of Nursing (ADON) confirmed that Norco was available in the emergency kit and should have been administered as ordered. The facility's medication administration policy required timely and safe medication delivery based on resident need, not staff convenience. The failure to assess and provide pain relief resulted in the resident waiting approximately two hours without intervention.
Failure to Administer Medications as Prescribed and on Schedule
Penalty
Summary
A deficiency occurred when a resident did not receive their scheduled morning medications in a timely manner. The resident, who typically received medications at 7:30 AM, reported not having received any of her morning medications by 12:05 PM, despite using the call light multiple times to request them. Staff interviews confirmed that the resident's medications, which included treatments for high blood pressure, pain, depression, and respiratory conditions, were due at 8 AM and 9 AM but were not administered until after noon. The licensed nurse acknowledged that thirteen morning medications were given late, and as a result, some noon medications could not be administered as scheduled due to the close timing. Review of the Medication Administration Record (MAR) and facility policy confirmed that the medications were documented as given after 12 PM, outside the facility's policy requiring medications to be administered within 60 minutes of the scheduled time. The Director of Nursing verified that the late administration contradicted physician orders and facility procedures. The resident's medical conditions included high blood pressure, COPD, asthma, and pain, and the medications involved were critical to managing these conditions. The failure to administer medications as prescribed was directly observed and confirmed through interviews and record review.
Medication Storage and Labeling Deficiencies Identified in Medication Carts
Penalty
Summary
Surveyors identified multiple failures in medication storage practices involving two out of five medication carts. Opened medications, including antacids, multivitamins, iron tablets, probiotics, nephro vitamins, and folic acid, were found in the carts without opened-on dates. Licensed nurses confirmed that these medications should have been labeled with the date they were first opened, as required by facility policy. The Director of Nursing (DON) also acknowledged that over-the-counter medications in the carts should have been labeled accordingly. Additionally, an opened bottle of acidophilus, an over-the-counter probiotic, was found stored in a medication cart drawer instead of being refrigerated as required by the manufacturer's instructions. The DON confirmed that the medication was not stored according to the guidelines on the bottle's label, which could result in reduced effectiveness and potency. Facility policy requires medications needing refrigeration to be stored in a designated refrigerator in a secure location. Further, a hazardous medication, risperidone, was found in a bubble pack labeled as hazardous but was not stored in a protective plastic bag as required. The DON stated that hazardous medications should be stored in such bags to prevent staff exposure. In another instance, a resident's rings were found in a plastic bag labeled only with a room number and stored in a medication cart drawer. The DON confirmed that resident belongings should not be kept in medication carts and should be given to Social Services, as storing them in the cart poses a risk of loss.
Failure to Follow Prescribed Menu Portion Sizes and Serve Palatable Food
Penalty
Summary
During a lunch service, the facility failed to follow the prescribed portion sizes for mashed sweet potatoes (yams) and vegetables, and served roast beef with blackened edges to 107 residents. Observations revealed that the cook used a gray scoop for all yams and vegetables, regardless of the specific portion sizes indicated for different diets on the facility's Spring Cycle Menus. The roast beef was plated with blackened edges and covered with barbecue sauce without removing the overcooked portions. The Food Services Director (FD) acknowledged that the expectation was for better preparation in the future and confirmed that the overcooked roast beef was not palatable. Review of the menus and interviews with the Registered Dietitian (RD) and FD confirmed that the correct scoop sizes and portion amounts, as specified for various diets, were not followed during the meal service. The RD stated that different portion sizes were required for different prescribed diets and that the cook's spreadsheet and posted charts provided this information. The FD confirmed that the facility's policy for portion sizes was not followed, despite in-services and posted guides. The facility's policy also stated that poorly prepared food should not be served, but this was not adhered to during the observed meal service.
Medication Error Leads to Resident's Death
Penalty
Summary
The facility failed to ensure safe medication practices for a resident who was admitted after experiencing multiple health complications, including a gallbladder rupture and a blood clot in the lung. Upon admission, the resident was prescribed two blood thinner medications, Rivaroxaban and Dabigatran, which were administered concurrently for 3.5 days. This concurrent administration was not clarified with the medical doctor, leading to a critically high Prothrombin Time/International Normalized Ratio (PT/INR) and subsequent transfer to the Emergency Department. The error in medication administration was attributed to a clerical mistake in the facility's electronic health record system, which reset the start date for Dabigatran. The nursing staff followed the computer system prompts for medication administration without recognizing the duplication. The facility's Assistant Director of Nursing (ADON) and Licensed Nurses (LNs) involved did not identify the error until after the medications had been administered for several days, and there was a delay in contacting the medical doctor to address the issue. As a result of the medication error, the resident suffered severe complications, including internal bleeding, cardiogenic shock, and ultimately death. The facility's policies on medication administration and communication with medical providers were not adequately followed, contributing to the oversight and delay in addressing the critical condition of the resident.
Medication Administration and Identification Failures
Penalty
Summary
The facility failed to ensure professional standards of care were met for three residents, resulting in untimely administration of medications. Resident 1, diagnosed with Parkinsonism, experienced delays in receiving Parkinson's medications, which were administered hours after the scheduled times on multiple occasions. This delay was confirmed by the Medication Admin Audit Report and acknowledged by the Director of Nurses (DON), who emphasized the importance of timely medication administration for maintaining therapeutic efficacy. Resident 2, with heart failure and type 2 diabetes, also experienced delays in receiving diabetes and blood pressure medications. The medications were administered nearly two hours late on consecutive days, as confirmed by the Medication Admin Audit Report and a licensed nurse. Similarly, Resident 3, diagnosed with hypertensive heart disease, received her medications over three hours late. The DON confirmed that medications should be administered within one hour of their scheduled time to maintain consistent blood levels and prevent complications. Additionally, Resident 1 did not receive timely interventions for constipation, with no bowel movement recorded from admission until nine days later, despite family notification of the issue. The facility's bowel care protocol was not followed, as laxatives were only administered after a significant delay. Furthermore, Resident 1's clinical documents contained a photo of another resident, raising concerns about potential misidentification and incorrect treatment. The DON acknowledged the importance of accurate resident identification through photos and ID bands to prevent medication errors.
Medication Mismanagement Leads to Privacy Breach
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records when medication intended for one resident was mistakenly sent home with another. Resident 4, who was admitted with a diagnosis of essential hypertension, had an order for clonidine tablets, which were delivered to the facility. However, these medications were inadvertently sent home with Resident 1 upon their discharge. This error resulted in unauthorized access to Resident 4's health and personal information. The Director of Nurses (DON) acknowledged that Resident 4's clonidine had been discontinued the same day it was ordered, and the medication was supposed to remain in the medication storage room until proper disposal. The DON explained that the nurse responsible for discharging a resident is expected to review all medications to ensure the correct ones are sent home. The failure to do so not only posed a risk of incorrect medication usage for Resident 1 but also constituted a HIPAA compliance risk for Resident 4. The facility's job description for Licensed Vocational Nurses emphasizes the responsibility to maintain the confidentiality of all resident care information.
Unsafe Discharge of Resident Without Adequate Support
Penalty
Summary
The facility failed to ensure a safe and effective transition of care for a resident who was discharged home despite being unable to care for herself. The resident, who had chronic respiratory failure, muscle weakness, gait abnormalities, and morbid obesity, was discharged without adequate preparation for her home environment, which included three steps at the entrance. The physical therapy evaluation noted that the resident was not tested on stairs due to safety concerns, and the occupational therapist indicated that the resident required assistance that was not available. The discharge was marked as planned, but there was confusion regarding whether it was against medical advice (AMA). The Social Services Director stated that the resident's insurance did not allow for an extension of stay, leading to the discharge decision. The resident's family expressed concerns about her ability to manage at home, citing her weight and mobility issues, and reported that the facility threatened to discharge her to the street. The family had to call the Fire Department to assist the resident back to the hospital after her discharge. The facility's actions were further questioned by Adult Protective Services, which stated that the facility discharged the resident knowing it was unsafe. The facility's policy required a physician's order for discharge unless it was AMA, but there was no AMA form in the resident's record. The facility also failed to assist the resident with safe discharge planning or completing necessary applications for public health insurance, contributing to the unsafe discharge situation.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, who had a history of inappropriate behaviors. Resident 2, with an intact memory as indicated by a BIMS score of 15, inappropriately touched Resident 1's thigh and Resident 3's abdomen and groin without consent. Resident 1 reported that Resident 2 entered his room multiple times, causing fear and distress, leading to his discharge against medical advice. Resident 3 was also a victim when Resident 2 entered his room while he was sleeping and touched him inappropriately. The facility's documentation and monitoring of Resident 2 were inadequate. Despite being aware of Resident 2's inappropriate behavior, the facility's 30-minute monitoring forms were incomplete, with missing dates, resident names, and initials, making it impossible to confirm Resident 2's whereabouts. Interviews with staff revealed that Resident 2 was able to enter other residents' rooms unnoticed, indicating lapses in supervision and monitoring. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents involving Resident 2. The Social Services Director confirmed that Resident 2 continued to enter other residents' rooms despite being instructed not to. The Administrator acknowledged the gaps in monitoring documentation and recognized Resident 2's behaviors as predatory, posing a risk to other residents.
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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