Crenshaw Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 1900 S Longwood Ave, Los Angeles, California 90016
- CMS Provider Number
- 055525
- Inspections on file
- 40
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Crenshaw Nursing Home during CMS and state inspections, most recent first.
A CNA failed to provide respectful and dignified care to a resident requiring assistance with toileting and hygiene, instead speaking rudely and refusing to help, which left the resident feeling upset. Another resident and facility leadership confirmed the inappropriate behavior, which was not in line with facility policy requiring respectful and prompt care.
A resident with significant physical impairments reported being physically and verbally mistreated by a CNA, and the incident was not reported to authorities within the required two-hour timeframe as mandated by facility policy. Another resident confirmed the rude behavior, and the delay in reporting resulted in a postponed investigation by the state health department.
A resident with severe cognitive impairment and multiple care needs was discharged without proper IDT planning, to a private home that was not equipped to meet their needs. The discharge was arranged by a marketer, with no verification of the location, no involvement of the family in the decision, and no notification to the Ombudsman or Local Contact Agency. The resident was sent without proper documentation, medication management, or follow-up, and was later found unconscious and hospitalized for altered mental status and infection.
The facility failed to obtain informed consent before administering lorazepam to two residents with severe cognitive impairments, violating their rights to make informed decisions. The Minimum Data Set Nurse confirmed the absence of documentation for informed consent, which is required by the facility's policy.
The facility did not ensure that the most recent survey results were posted in a location readily accessible to residents. A sign at the Annex Station indicated survey information was available upon request, but the survey binder was not near the signage or the nurse's station. The DON confirmed that survey results should have been freely accessible to all residents. The facility's policy stated that residents have the right to examine survey results and any plan of correction, which should be available in a readily accessible place.
The facility failed to correctly set low air loss mattresses (LALM) for two residents, risking skin breakdown due to incorrect weight settings. Additionally, a resident with an unstageable pressure ulcer did not receive a prescribed LALM, potentially worsening their condition. These actions violated facility protocols for pressure ulcer prevention and management.
The facility failed to maintain the medication room storage refrigerator at the required temperature, as outlined in their policy. The refrigerator contained unopened insulin vials, insulin pens, and multidose tuberculin injection vials, with the temperature recorded at 48 degrees Fahrenheit, exceeding the policy requirement of 36-46 degrees Fahrenheit. An LVN confirmed the temperature discrepancy and acknowledged the risk of medications expiring.
A resident with a urinary catheter did not have a privacy bag covering the collection bag, violating their right to dignity and privacy. The resident, who had anxiety disorder and other medical conditions, was capable of understanding and decision-making. An LVN confirmed the importance of covering the catheter bag, as per the facility's dignity policy.
A resident with chronic conditions and right-sided weakness had their call light placed on the floor behind their bed, making it inaccessible. The resident's care plan required the call light to be within reach, but this was not followed, as confirmed by an LVN. The facility's policy also emphasized the importance of call light accessibility for prompt assistance.
A facility failed to develop a baseline care plan for a resident on dialysis within 48 hours of admission, as required by their policy. The resident, who had ESRD, hypertension, and anemia, required dialysis treatment three times a week. Despite having the mental capacity to make medical decisions, the resident's care plan was not established, which was confirmed by the MDS Nurse. This omission could affect the resident's dialysis care and treatment.
A facility failed to develop a care plan for a resident receiving oxygen therapy, as identified during a review of records and an interview with an LVN. The resident, with diagnoses including ESRD, DM, and dementia, required respiratory treatment with O2. The LVN confirmed the absence of a care plan, which was necessary to outline services, track interventions, and monitor outcomes. The facility's policy required care plans to include measurable objectives and reflect current standards of practice.
A resident with End Stage Renal Disease and a physician's order for Midodrine was not monitored for blood pressure every 8 hours as required. This failure was confirmed by an LVN and the DON, who acknowledged the importance of monitoring to adjust medication and ensure safety. The facility's policies on medication administration and care for residents with ESRD were not followed.
The facility failed to provide adequate respiratory care for two residents, leading to potential infection risks. A resident with a tracheostomy had dried secretions on the site and tube due to inconsistent care, while another resident's nebulizer tubing was not dated, making it unclear when it was last changed. These lapses in care violated the facility's policies for respiratory care and equipment maintenance.
A facility failed to monitor and record a resident's blood pressure every 8 hours as required for a resident receiving hemodialysis and prescribed midodrine for low blood pressure. The resident's blood pressure was not monitored according to the physician's order, which is essential for medication administration and resident safety. Both the LVN and DON acknowledged the importance of this practice, yet it was not followed, resulting in a deficiency.
The facility failed to act on pharmacist consultant recommendations for two residents, risking unnecessary medication administration. One resident's lorazepam order could exceed the recommended dose, while another's lacked a stop date, violating CMS rules. The DON confirmed no follow-up documentation with physicians, contrary to facility policy.
Two residents receiving PRN lorazepam for anxiety were not reevaluated after 14 days, contrary to facility policy. Both residents had severely impaired cognitive skills and required significant assistance from staff. The DON confirmed the absence of a stop date and reevaluation, which could lead to unnecessary medication use.
The facility failed to maintain proper food safety standards, with a malfunctioning thermometer in Kitchen Refrigerator 1 and an unlabeled pasta bin in dry storage. Additionally, Kitchen Refrigerator 2 was found to have an internal temperature above the recommended level, posing a risk of expired food. These issues were observed during a survey, highlighting deficiencies in the facility's adherence to its own policies.
A facility failed to change and label the humidifier for a resident's oxygen therapy, as required by policy. The resident, with a history of ESRD, DM, and dementia, required respiratory treatment. An LVN confirmed the humidifier was undated, risking respiratory infection.
The facility did not meet the required 80 square feet per resident in several rooms, as confirmed by a waiver request and room measurements. The DON acknowledged the issue, noting potential movement restrictions for residents, though no harm was reported. Observations indicated no adverse effects on residents' health or safety, and a waiver was recommended.
A deficiency occurred when a resident-to-resident physical altercation was not timely reported to the CDPH, delaying the investigation and placing a resident at risk for further abuse. The incident involved two residents with intact cognitive skills and various medical conditions. A CNA observed one resident slap the other, but the LVN and DON lacked evidence of reporting the incident as required by facility policy.
A resident with schizophrenia and major depressive disorder, under 24/7 one-on-one care, sustained multiple unexplained injuries that were not reported to CDPH within the required timeframe. Despite being monitored, the resident experienced a swollen tibia and fibula, a swollen left wrist, and skin discolorations, which were not reported as per the facility's policy.
A resident with cognitive impairment and on one-on-one care sustained multiple injuries of unknown origin, which the facility failed to investigate on three occasions. Despite constant supervision, the facility did not document or investigate the causes of the injuries, contrary to their policy requiring thorough investigation and reporting of such incidents.
A facility failed to create an individualized care plan for a resident with schizophrenia and major depressive disorder, who required constant supervision due to a high risk of falls. The care plan lacked specific monitoring details and did not address the resident's unsteady gait, lack of shoes, or abrupt behavior. An incident occurred where the resident fell and was injured, revealing the care plan's inadequacy.
A resident with schizophrenia and major depressive disorder experienced multiple incidents of bruising and swelling due to the facility's failure to provide an environment free from accident hazards and adequate supervision. The resident's fall risk assessment was inaccurate, leading to insufficient interventions for their high fall risk. The facility also did not implement its policy for safety and supervision, resulting in unaddressed safety risks and environmental hazards.
A resident with dysphagia was served the wrong diet, contrary to physician orders, placing them at risk for aspiration. Despite reporting the error to the administration and DON, no follow-up actions were communicated. Interviews confirmed the dietary mistake and the associated risks, highlighting a failure in adhering to the facility's policy for resident-centered diet planning.
A resident with unstageable pressure ulcers was not provided with a low air loss mattress, essential for wound management, despite being at high risk for skin breakdown. The facility failed to order the mattress, citing insurance approval delays, and did not adhere to its policy of providing appropriate support surfaces for high-risk residents.
A resident with cognitive impairments and fall risk was left unsupervised during the night shift while a CNA was asleep at the nurse's station. The resident's care plan required frequent observation and assistance with ADLs, which was not provided, leading to a deficiency in supervision and safety.
The facility failed to maintain a sanitary environment, with observations of dirty stains, mouse droppings, and clutter in resident rooms, laundry, and shower areas. Housekeeping staff admitted to inconsistent deep cleaning practices, and documentation was lacking. The Infection Control Nurse and DON stressed the importance of cleanliness to prevent infections, but facility standards were not consistently met.
A resident with schizoaffective disorder and other conditions reported pain and discoloration in the right index finger, but the complaint was not documented by the LVN as required by facility protocol. This lack of documentation was identified during interviews with staff, highlighting a failure to follow procedures for recording changes in a resident's condition.
A resident in an LTC facility was subjected to repeated physical abuse by another resident, resulting in injuries. Despite reports of the abuse, the facility failed to separate the residents or update their care plans, leading to further harm. The facility's staff did not follow protocols for documenting incidents or ensuring resident safety, contributing to the deficiency.
A facility failed to implement its abuse prevention policy, resulting in a resident being repeatedly hit by a roommate. Despite known issues with the aggressor's behavior, staff did not separate the residents or update care plans. The DON was unaware of the initial incident, and the facility's inaction placed residents at risk for further abuse.
The facility failed to report alleged abuse incidents involving two residents to the CDPH within the required two-hour timeframe. One resident reported being physically assaulted by their roommate, resulting in visible injuries. Despite staff observations and reports, the residents were not separated, and the DON misunderstood the reporting requirements, delaying the investigation process.
A facility failed to investigate a resident-to-resident altercation, leading to a subsequent incident where a resident was hit, resulting in a bruise and swelling. Despite reports of feeling unsafe, the facility did not separate the residents. The resident with a history of aggression was not adequately monitored, and staff failed to follow abuse reporting protocols, leaving the affected resident at risk.
A facility failed to develop a comprehensive abuse care plan after two incidents where a resident with schizophrenia physically abused another resident, resulting in injuries. Despite staff awareness and policy requirements, no care plans were initiated, and the residents were not separated, leading to repeated abuse.
Failure to Treat Resident with Dignity During Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to treat a resident with dignity and respect during care. The resident, who had hemiplegia, hemiparesis, osteoarthritis, and was always incontinent of urine, required partial to moderate assistance for activities of daily living, including toileting hygiene. The resident reported that the CNA on the night shift pushed on his leg, hit him with a pillow, and spoke to him in a rude and dismissive manner, telling him to clean himself. This interaction left the resident feeling frustrated, upset, and reluctant to request further assistance. Another resident, who also required partial to moderate assistance for daily care, confirmed that the CNA spoke rudely to the first resident, instructing him to change himself if he did not want to wait. The Director of Staff Development and the Director of Nursing both acknowledged that the CNA's behavior was inappropriate and not in accordance with facility policy, which requires staff to treat residents with dignity and respond promptly and respectfully to care requests. The facility's policy prohibits demeaning practices and mandates respectful communication at all times.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to implement its policies and procedures regarding the timely reporting of an abuse allegation for one of three sampled residents. Specifically, a resident with hemiplegia, hemiparesis, and osteoarthritis reported to the Director of Staff Development (DSD) that a Certified Nursing Assistant (CNA) had pushed on his leg, hit him with a pillow, and spoken to him in a rude and disrespectful manner during care. The DSD acknowledged that these actions constituted abuse and that, according to facility policy, such allegations must be reported to the California Department of Public Health (CDPH) and other agencies within two hours. However, the report was not made within the required timeframe, resulting in a delay in the investigation by CDPH. Interviews and record reviews confirmed that the resident was able to make decisions for activities of daily living and required moderate assistance for personal care. Another resident corroborated that the CNA had spoken rudely to the affected resident. The facility's policy clearly stated that abuse allegations must be reported immediately, defined as within two hours, and that employees involved would be placed on leave pending investigation. Despite these policies, the required timely reporting did not occur in this instance.
Failure to Ensure Safe Discharge Planning for Cognitively Impaired Resident
Penalty
Summary
A resident with severe cognitive impairment, dementia, schizophrenia, and a history of falls was discharged from the facility without proper discharge planning or interdisciplinary team (IDT) involvement. The resident required significant assistance with activities of daily living, was on antipsychotic and nerve pain medications, and had a care plan indicating the need for one-on-one supervision due to poor safety awareness. Despite these needs, there was no evidence of an IDT meeting or discharge care plan prior to the resident's discharge, and the resident's physician was not notified or involved in the discharge decision. The discharge location was a private home, not an assisted living or dementia care unit, and was arranged by a facility marketer without verification that the location could meet the resident's needs. The address provided to the family could not be verified, and the landlord of the home was not a healthcare professional and was unaware of the resident's medical requirements. The resident's family was not involved in selecting the discharge location, and the facility failed to notify the Local Contact Agency or the Ombudsman of the discharge. No discharge documents or information were provided to the receiving location, and there was no follow-up to ensure the resident was safely settled. Upon arrival at the home, the resident was found to be in poor condition, non-verbal, and later became unconscious, requiring emergency transfer to a hospital where a urinary tract infection and altered mental status were identified. The facility did not document the medications sent with the resident, did not ensure a responsible party was available to administer medications, and failed to provide necessary education or instructions regarding medication administration. The facility's actions were not in accordance with its own policies and procedures for safe discharge, notification, and documentation.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before administering psychotropic medication to two residents, violating their right to make informed decisions about their treatment. Resident 16, who was diagnosed with anxiety disorder, COPD, and dementia, was given lorazepam without documented informed consent. The resident's cognitive skills were severely impaired, and they were dependent on staff for daily activities. Similarly, Resident 41, with diagnoses including anxiety disorder, anemia, and protein calorie malnutrition, also received lorazepam without informed consent. This resident also had severely impaired cognitive skills and required maximal assistance for daily activities. During a review of the clinical records, it was found that there was no documentation indicating that the physician had obtained informed consent or discussed the side effects of lorazepam with the residents or their representatives. The facility's policy requires that residents or their representatives be informed of their health status and treatment options, including the right to decline psychotropic medications. The Minimum Data Set Nurse confirmed the lack of informed consent documentation and acknowledged that administering the medication without it was a violation of resident rights.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the most recent survey were posted in a location readily accessible to residents. During an observation at the Annex Station, a sign was noted indicating that CDPH survey information was available upon request, but the survey binder was not placed near the signage or around the nurse's station. The Director of Nursing (DON) confirmed that all recertification survey results should have been in a folder at the nursing station, freely accessible to all residents. The absence of the survey binder could result in residents not being informed of the facility's previous survey information and any corrections made. The facility's policy and procedures indicated that residents have the right to examine the results of the most recent survey and any plan of correction, and these should be made available in a place readily accessible to residents.
Failure to Properly Set and Provide Low Air Loss Mattresses
Penalty
Summary
The facility failed to ensure that the low air loss mattresses (LALM) for two residents, Resident 16 and Resident 41, were set and maintained at the correct settings according to the manufacturer's guidelines. Both residents were at high risk for developing pressure ulcers due to their medical conditions and required the LALM for skin maintenance. During an observation, it was found that the LALM settings for Resident 16 and Resident 41 were incorrectly set at 300 lbs. and 350 lbs., respectively, despite their actual weights being 106 lbs. and 87 lbs. The Licensed Vocational Nurse (LVN) acknowledged the incorrect settings and stated that the settings should be based on the residents' current weights to prevent skin breakdown. Additionally, the facility failed to provide a LALM for Resident 105, who had an unstageable pressure ulcer and was at high risk for further skin breakdown. Despite having a physician's order for a LALM to maintain skin integrity, the mattress was not provided. The Director of Nursing (DON) confirmed the absence of the LALM and acknowledged the potential for the resident's wound to worsen due to the delay in providing the necessary equipment. The facility's policies and procedures for pressure-reducing mattresses and pressure ulcer management were not followed, as evidenced by the incorrect settings of the LALM for Residents 16 and 41 and the lack of a LALM for Resident 105. The facility's failure to adhere to these protocols placed the residents at risk for discomfort, skin breakdown, and potential worsening of existing pressure ulcers.
Medication Storage Temperature Deficiency
Penalty
Summary
The facility failed to maintain the medication room storage refrigerator at the required temperature, as outlined in their policy and procedure titled 'Medication Storage in the Facility.' During an observation, the refrigerator was found to contain unopened insulin vials, insulin pens, and unopened multidose tuberculin injection vials, with the temperature recorded at 48 degrees Fahrenheit. This temperature exceeded the facility's policy requirement of maintaining between 36-46 degrees Fahrenheit. During an interview, a Licensed Vocational Nurse confirmed the temperature discrepancy and acknowledged that an out-of-range temperature could result in medications expiring.
Failure to Provide Privacy for Urinary Catheter
Penalty
Summary
The facility failed to provide a privacy bag for a resident with a urinary catheter, which is a violation of the resident's right to dignity and privacy. The deficiency was identified during an observation where the resident's urinary catheter collection bag was visible and uncovered, hanging on the side of the bed. This oversight was confirmed during an interview with an LVN, who acknowledged the importance of covering the catheter bag to prevent discomfort and maintain the resident's dignity. The resident involved had been admitted with diagnoses including anxiety disorder, kidney calculus, and cerebral infarction. The resident was capable of understanding and making decisions, as indicated in their medical records. The facility's policy on dignity, which mandates that urinary catheter bags be covered to enhance residents' well-being and self-esteem, was not adhered to in this instance, leading to the identified deficiency.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of the resident. The resident, identified as Resident 44, was observed to have their call light on the floor behind their bed, making it inaccessible. This observation was made during a room visit, and it was noted that the resident had right-sided weakness, making it essential for the call light to be placed on their functional left side. The resident's care plan specifically indicated that the call light should be within reach to attend to their needs promptly. Resident 44 had a medical history that included chronic obstructive pulmonary disease, epilepsy, and diabetes mellitus, and was dependent on staff for activities of daily living such as showering, dressing, and personal hygiene. The facility's policy and procedure on call lights emphasized the importance of ensuring that call lights are within reach to provide prompt assistance. However, this policy was not adhered to in the case of Resident 44, as confirmed by an interview with an LVN who acknowledged the necessity of having the call light accessible to the resident.
Failure to Develop Baseline Care Plan for Dialysis Resident
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was on dialysis, which is a critical treatment for individuals with End Stage Renal Disease (ESRD). The resident, identified as having the mental capacity to make medical decisions, was admitted with diagnoses including ESRD, hypertension, and anemia. Despite the resident's need for dialysis treatment every Tuesday, Thursday, and Saturday, as indicated in the physician's order, the facility did not create a baseline care plan within 48 hours of admission. This omission was confirmed during a review of the resident's clinical records and an interview with the Minimum Data Set Nurse (MDSN). The facility's policy and procedure on baseline care plans, dated March 2022, mandates that a baseline plan of care should be developed within 48 hours of a resident's admission to address immediate health and safety needs. The MDSN acknowledged that the absence of a baseline care plan meant that the facility staff would not be able to properly assess and manage the resident's dialysis needs. This deficiency had the potential to impact the resident's care and treatment specific to their dialysis requirements.
Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a care plan for a resident, identified as Resident 105, who was receiving oxygen therapy. This deficiency was identified during a review of the resident's records and an interview with a Licensed Vocational Nurse (LVN). The resident, who had been initially admitted and later readmitted to the facility, had diagnoses including end-stage renal disease, diabetes mellitus, and dementia. The Minimum Data Set (MDS) assessment indicated that the resident had moderately impaired cognition and was dependent on staff for activities such as showering and dressing. The MDS also noted the resident's requirement for respiratory treatment with oxygen therapy. During an interview, LVN 2 confirmed that there was no care plan in place to address the resident's use of oxygen. The LVN emphasized the importance of having a care plan to outline the necessary services, track interventions, and monitor outcomes related to the resident's oxygen use. The facility's policy and procedure on care plans, dated March 2022, required that care plans include measurable objectives, timeframes, and reflect current standards of practice. The absence of a care plan for Resident 105's oxygen therapy meant that there were no documented goals or interventions to guide the staff in providing appropriate care.
Failure to Monitor Blood Pressure for Resident on Midodrine
Penalty
Summary
The facility failed to monitor and record the blood pressure of Resident 202, who had a physician's order for Midodrine to be administered every 8 hours as needed for systolic blood pressure (SBP) less than 120. This oversight was identified during a review of Resident 202's Medication Administration Record (MAR) and confirmed by Licensed Vocational Nurse (LVN) 3, who acknowledged that the standard of practice was not followed. The LVN stated that monitoring blood pressure every 8 hours was crucial for adjusting medication and ensuring the resident's safety. Resident 202 was admitted with diagnoses including End Stage Renal Disease, hypertension, and anemia, and had the mental capacity to make medical decisions. The Director of Nursing (DON) confirmed that the order for Midodrine was intended to maintain stable blood pressure, especially during dialysis treatment. The facility's policies on care for residents with End Stage Renal Disease and medication administration were not adhered to, as they require medications to be administered according to physician orders and emphasize the importance of timing and administration of medications, particularly around dialysis sessions.
Inadequate Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, leading to potential risks of respiratory infection. Resident 12, who has a tracheostomy due to chronic obstructive pulmonary disease and neck cancer, was found with dried secretions on the tracheostomy site and tube. Despite a physician's order to cleanse the tracheostomy site daily, the care was not performed consistently, as confirmed by the Director of Nursing. The facility's policy requires tracheostomy care every shift to ensure airway patency and minimize infection risk, but this was not adhered to, as evidenced by the presence of dried secretions and missed care on specific dates. Resident 16, diagnosed with COPD, anxiety disorder, and dementia, had a face mask nebulizer tubing that was not labeled with the date of change. The Licensed Vocational Nurse was unable to determine when the tubing was last changed, which is required weekly for safety and infection control. The facility's policy mandates weekly changes of respiratory equipment, including nebulizer tubing, but this was not followed, creating a potential risk for respiratory infection. These deficiencies highlight lapses in the facility's adherence to respiratory care protocols for residents with significant respiratory needs.
Failure to Monitor Blood Pressure for Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident receiving hemodialysis by not monitoring and recording the resident's blood pressure every 8 hours as required. The resident, who was diagnosed with End Stage Renal Disease, hypertension, and anemia, was prescribed midodrine to manage low blood pressure, with specific instructions to administer the medication if the systolic blood pressure was less than 120. However, the facility did not adhere to the physician's order to monitor the resident's blood pressure every 8 hours, which is crucial for determining when to administer the medication. Licensed Vocational Nurse 3 confirmed that the resident's blood pressure was not monitored as required, acknowledging the importance of this practice for medication adjustment and resident safety. The Director of Nursing also recognized the necessity of monitoring the resident's blood pressure to prevent hypotension, especially during dialysis treatment. The facility's policies on care for residents with End Stage Renal Disease and medication administration emphasize adherence to physician orders, yet these were not followed, leading to the deficiency.
Failure to Act on Pharmacist Recommendations for Two Residents
Penalty
Summary
The facility failed to act on the pharmacist consultant's recommendations in a timely manner for two residents, placing them at risk for unnecessary medication administration. Resident 16, who was diagnosed with anxiety disorder, COPD, and dementia, had a physician's order for lorazepam that could potentially exceed the recommended maximum daily dose for the elderly. The pharmacist consultant recommended that the physician re-evaluate the order or document the risk and benefit if the current order was indicated. However, there was no documentation indicating that the licensed nursing staff followed up with the physician regarding this recommendation. Similarly, Resident 41, who had diagnoses including anxiety disorder, anemia, and protein calorie malnutrition, was prescribed lorazepam without a stop date, contrary to CMS Mega Rules requiring documentation of rationale and duration for psychotropic drug orders beyond 14 days. The pharmacist consultant noted this issue, but again, there was no documentation of follow-up with the physician. The Director of Nursing confirmed that the clinical records for both residents lacked documentation of follow-up actions, which was against the facility's policy requiring timely action on pharmacist recommendations.
Failure to Reevaluate PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents, who were receiving PRN psychotropic medication, were reevaluated after 14 days as required. Resident 16, who had diagnoses including anxiety disorder, COPD, and dementia, was prescribed lorazepam to be taken as needed for anxiety. The resident's cognitive skills were severely impaired, and they were dependent on staff for daily activities. Similarly, Resident 41, with diagnoses of anxiety disorder, anemia, and protein calorie malnutrition, was also prescribed lorazepam PRN for anxiety. This resident also had severely impaired cognitive skills and required maximal assistance from staff. The Director of Nursing acknowledged that both residents were on lorazepam PRN without a specified duration of therapy, which is against the facility's policy. The facility's policy requires that PRN psychotropic medications have a stop date and that the physician should document the rationale for extending the use beyond 14 days. The lack of a stop date and reevaluation placed the residents at risk of receiving unnecessary medication, as there was no documented justification for the continued use of lorazepam beyond the initial 14-day period.
Deficiencies in Kitchen Food Safety Standards
Penalty
Summary
The facility failed to maintain proper food safety standards in their kitchen, as observed during a survey. The external thermometer of Kitchen Refrigerator 1 was malfunctioning, as it was observed counting upwards in seconds and minutes starting from zero, which was confirmed by a Dietary Aide who was unaware of the malfunction. This malfunction posed a risk of spoiled food due to the inability to monitor the refrigerator's temperature accurately. Additionally, the large clear egg noodle pasta bin in the dry storage area was not labeled with a name and date, which could lead to uncertainty about the contents and their expiration. Furthermore, Kitchen Refrigerator 2 was found to have an internal temperature of 42 degrees Fahrenheit, which is above the recommended 40 degrees Fahrenheit or lower, as stated in the facility's policy. The Dietary Supervisor acknowledged this discrepancy and the potential risk of expired food due to improper temperature maintenance. The facility's policies on refrigerator and dry goods storage were reviewed, indicating that temperatures should be monitored and food items should be labeled and dated, but these procedures were not followed, leading to the deficiencies noted.
Failure to Change and Label Humidifier for Resident's Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the humidifier used for a resident's oxygen therapy was changed and labeled with the date, as required by the facility's policy. This oversight was identified during an observation in the resident's room, where the humidifier attached to the oxygen concentrator was found to be undated and unlabeled. The facility's policy mandates that the oxygen humidifier should be changed weekly and as needed, but this was not adhered to in this instance. The resident involved, who was dependent on staff for various activities of daily living, had a medical history that included end-stage renal disease, diabetes mellitus, and dementia. The resident required respiratory treatment with oxygen therapy, making the proper maintenance of the humidifier crucial. During an interview, a Licensed Vocational Nurse confirmed that the lack of a date label on the humidifier made it impossible to verify if it had been changed as required, thereby placing the resident at risk for developing a respiratory infection.
Facility Fails to Meet Required Room Size Standards
Penalty
Summary
The facility failed to meet the required 80 square feet per resident in several rooms, specifically in House Station Rooms 1, 2, 3, 4, 6, 8, 9, and 10, as well as Annex Station room. This deficiency was identified through observation, interviews, and record reviews. The facility's document titled 'Request for Waiver Variation Letter' dated 3/18/2025, confirmed that these rooms did not meet the required square footage per resident. The Client Analysis form further detailed the measurements of these rooms, showing that the space allocated per resident was below the required standard. During an interview, the DON acknowledged that the Administrator had submitted a room waiver form and confirmed that some rooms were smaller than the required size. The DON noted that the lack of adequate space could potentially restrict residents' movement, although no harm was reported to have occurred to the residents in the affected rooms. Observations made during the survey period indicated that the room sizes did not adversely affect the residents' health or safety. The Department recommended a waiver for the facility.
Failure to Timely Report Resident Altercation
Penalty
Summary
The deficiency involves a failure to timely report a resident-to-resident physical altercation to the California Department of Public Health (CDPH), which delayed the investigation and placed one resident at risk for further abuse. The incident involved two residents, one with a history of schizophrenia, bipolar disorder, epilepsy, and insomnia, and the other with osteoarthritis, hypertension, muscle weakness, and cellulitis. Both residents had intact cognitive skills and required supervision with activities of daily living. The altercation occurred when one resident attempted to enter through a door where the other was sitting, leading to a verbal exchange and an alleged physical slap by one resident, as observed by a Certified Nursing Assistant (CNA). The report indicates that the Licensed Vocational Nurse (LVN) claimed to have reported the incident to CDPH but lacked evidence of a fax confirmation or a written Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form. The Director of Nursing (DON) also stated that there was no confirmation of the report being made. The facility's policy requires immediate reporting of such incidents within two hours, but the lack of documentation and confirmation suggests a failure to comply with this policy, resulting in a delay in the investigation by CDPH and potential risk for further abuse to the resident involved.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report incidents of suspected abuse, neglect, or injury of unknown origin to the California Department of Public Health (CDPH) within the required timeframe for a resident who sustained multiple bruises and swellings. The resident, who had diagnoses of schizophrenia and major depressive disorder, was under one-on-one care due to impaired cognitive function and a high risk of falls. Despite being monitored 24/7, the resident experienced unexplained injuries on three separate occasions, which were not reported to CDPH as required by the facility's policy. The incidents involved the resident having a swollen tibia and fibula, a swollen left wrist, and skin discolorations on the left lower extremities. These injuries were documented in the resident's records, but there was no indication that they were reported to CDPH. Interviews with facility staff, including a Certified Nurse Assistant and the Administrator, revealed that the injuries were suspicious and should have been reported immediately. The facility's policy mandates that any injury of unknown source be reported to the administrator and state licensing agency within two hours if it results in serious bodily injury, or within 24 hours if it does not, which was not adhered to in these cases.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate multiple instances of swelling and bruises of unknown origin for a resident, identified as Resident 3, on three separate occasions: 6/18/2024, 11/5/2024, and 12/24/2024. Resident 3, who was admitted with schizophrenia and major depressive disorder, had impaired cognitive function and required assistance with daily activities. Despite being on one-on-one care due to poor balance and risk of falls, the facility did not conduct investigations into the causes of the injuries noted on these dates. Progress notes from the days following each incident did not document any investigation into the causes of the injuries. Interviews with staff, including a Certified Nurse Assistant and a Treatment Nurse, revealed that the facility was unaware of how the injuries occurred, despite the resident being under constant supervision. The Treatment Nurse expressed suspicion about the unexplained nature of the injuries, indicating that they should have been investigated. The facility's policy on abuse, neglect, and injuries of unknown source required thorough investigation and reporting, which was not adhered to in these instances. The facility administrator acknowledged the lack of investigation and the suspicious nature of the injuries, which should have prompted immediate action.
Failure to Develop Individualized Care Plan for Resident at Risk of Falls
Penalty
Summary
The facility failed to develop an individualized care plan for a resident who required constant supervision due to a high risk of falls and injuries. The resident, diagnosed with schizophrenia and major depressive disorder, was admitted with a care plan that aimed to prevent falls and injuries but lacked specific details on the frequency of monitoring. The resident's Minimum Data Set (MDS) indicated a need for supervision and assistance with activities of daily living, yet the care plan did not address the resident's unsteady gait, lack of shoes, or abrupt behavior. An incident occurred where the resident fell and sustained an injury, highlighting the inadequacy of the care plan. Interviews with staff revealed that the resident was on one-on-one supervision due to poor balance and self-awareness, but this was not reflected in the care plan. The Director of Nursing acknowledged the care plan's shortcomings, noting that it failed to include necessary interventions such as non-skid socks, psychological consultation, and constant supervision. The facility's policy required comprehensive, person-centered care plans with measurable objectives, which was not met in this case.
Failure to Prevent Accidents and Conduct Accurate Fall Risk Assessment
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not offer adequate supervision and assistance to prevent accidents for a resident with a history of falls. The resident, who had diagnoses including schizophrenia and major depressive disorder, experienced multiple incidents of bruising and swelling, including a swollen tibia and fibula, a swollen left wrist, and a bluish discoloration and swelling on the left eye. These incidents occurred despite the resident being on a care plan that aimed to keep them free from falls and injury, which included interventions such as frequent visible observation and safety instructions. The facility also failed to conduct an accurate fall risk assessment for the resident. The fall risk assessment did not account for the resident's history of falls, resulting in an incorrect classification of the resident as a low fall risk. This misclassification meant that the resident did not receive the necessary interventions for high fall risk individuals, such as increased supervision and safety measures. Interviews with facility staff revealed that the fall risk assessment should have included the resident's history of falls, which would have resulted in a high fall risk classification. Additionally, the facility did not implement its policy and procedure for safety and supervision of residents. The policy indicated that safety risks and environmental hazards should be identified on an ongoing basis, and the Quality Assurance and Performance Improvement (QAPI) team should review safety and incident/accident data. However, the facility did not know what caused the resident's injuries and could not address the specific problems that led to the bruises and swelling. The Director of Nursing acknowledged that the facility should have provided constant supervision to assist the resident in ambulation and prevent the incidents that occurred.
Dietary Error Puts Resident at Risk for Aspiration
Penalty
Summary
The facility's dietary staff failed to serve the correct food consistency to a resident as per the physician's order, which placed the resident at risk for potential aspiration. The resident, who had a diagnosis of dysphagia and muscle weakness, was supposed to receive a NAS diet with minced and moist texture and nectar/mildly thick consistency. However, on June 1, 2024, the resident was served a regular diet instead of the prescribed chopped diet. This error was reported by the resident and their family member to the administration and the director of nursing (DON), but no follow-up actions were communicated back to them. Interviews with various staff members, including the Registered Nurse and Dietary Supervisor, confirmed the incident and acknowledged the risk of aspiration due to the dietary error. The facility's policy indicated that a multidisciplinary team should assess and plan each resident's diet based on their nutritional needs and preferences. Despite this policy, the resident received the wrong diet, and the staff failed to communicate any interventions to prevent further errors. The DON, who was supposed to address the issue, was no longer with the facility, and it was unclear if any corrective actions were taken.
Failure to Provide Low Air Loss Mattress for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident who was admitted with unstageable pressure ulcers. The resident, who was at high risk for skin breakdown, was not provided with a low air loss mattress, which is essential for wound management and healing. Despite the resident's requests for a special mattress due to discomfort and pain, the facility did not take timely action to address this need. Interviews with staff revealed that there was no documented evidence of an order for the low air loss mattress, and the facility was waiting for insurance approval. The Treatment Nurse confirmed that all residents with pressure ulcers should have a low air loss mattress as part of their care plan. The Quality Assurance Nurse also emphasized the importance of the mattress in preventing further skin damage and stated that it was part of the facility's policy for residents at high risk of skin breakdown. The facility's policies and procedures indicated that appropriate support surfaces should be selected based on the resident's risk factors. However, the failure to provide the necessary mattress for the resident with pressure ulcers was a clear deviation from these guidelines. This oversight had the potential to worsen the resident's condition and contribute to further skin breakdown.
Inadequate Night Shift Supervision Leads to Resident Safety Risk
Penalty
Summary
The facility failed to provide adequate supervision during the night shift for a resident, identified as Resident 4, who was observed going to the bathroom unsupervised on multiple occasions. This occurred while a Certified Nurses Assistant (CNA) was asleep at the nurse's station. Resident 4 had a history of anxiety, Major Depressive Disorder, and dementia, and was assessed to be at risk for falls due to general weakness, poor balance, and cognitive deficits. The care plan for Resident 4 indicated that nursing staff should frequently observe the resident and assist with Activities of Daily Living (ADLs) as needed. Observations from facility camera footage confirmed that the CNA was asleep at the nurse's station during the times Resident 4 was unsupervised. Interviews with the CNA, the Director of Nursing (DON), and the Assistant Administrator (AADM) revealed that it was unacceptable for staff to sleep during working hours, as it compromised resident safety and care. The facility's policy emphasized the importance of resident supervision to prevent accidents, but this was not adhered to, leading to the deficiency.
Sanitation Deficiencies in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to maintain a sanitary environment for residents, as observed in multiple areas including resident rooms, the laundry area, and shower rooms. Observations revealed brown, dry, dirty stains on walls next to beds, old mouse droppings on the floor, and brown spots on walls near bathrooms. The laundry area was cluttered with dirty plastic bags and clothes on the floor, while the shower room had dry pieces of paper, hair, and black spots on the walls. Interviews with housekeeping staff indicated a lack of consistent deep cleaning practices, with one housekeeper unaware of who was responsible for checking and documenting deep cleaning, and another admitting that deep cleaning was not performed as scheduled. The Housekeeping Supervisor confirmed that deep cleaning should occur daily in one resident's room, but documentation was missing for several dates. The Infection Control Nurse and Director of Nursing emphasized the importance of maintaining a clean environment to prevent infections and ensure resident safety. The facility's policies outlined the need for clean and orderly conditions, but observations and interviews indicated these standards were not consistently met, leading to potential cross-contamination and pest activity.
Failure to Document Resident's Finger Injury
Penalty
Summary
The facility failed to ensure that a resident had a documented assessment for an injured right index finger after a notification of a change in condition. The resident, who was admitted with diagnoses including schizoaffective disorder, bipolar disorder, and metabolic encephalopathy, reported pain and discoloration in the right index finger to the Activities Director. The Activities Director then reported this to a Licensed Vocational Nurse (LVN), but there was no documentation of the complaint or the condition of the finger in the Progress Nurses Notes. Interviews with the LVNs and the Director of Nursing (DON) revealed that the lack of documentation was a breach of protocol, which requires that any changes in a resident's condition be recorded. The LVNs acknowledged the importance of documenting such complaints to communicate effectively with other staff and to ensure proper follow-up. The facility's policy and procedure on charting and documentation, as well as the job description for LVNs, emphasize the necessity of accurate and complete documentation of changes in a resident's condition.
Failure to Protect Resident from Repeated Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in multiple incidents of harm. Resident 1, who had intact cognition and required supervision with certain activities, reported being hit by Resident 2 on two separate occasions. Despite these reports, the facility did not take immediate action to separate the residents or update their care plans to prevent further abuse. Resident 1 sustained a red bruise and swelling around the right eyelid as a result of the abuse. Resident 2, diagnosed with schizophrenia and known for striking out behavior, was on antipsychotic medication. The facility's records indicated multiple episodes of striking out behavior by Resident 2, yet staff interventions were inadequate. The facility's policy required separating residents involved in abuse incidents, but this was not followed. Staff, including an LVN, failed to document the incidents properly, assess the residents, or implement a care plan to prevent recurrence. Interviews with staff and residents revealed that the facility was aware of the abuse incidents but did not take appropriate measures to ensure the safety of Resident 1. The DON admitted that the residents should have been separated after the first incident to prevent further abuse. The facility's failure to act according to its policy and procedures resulted in continued risk and harm to Resident 1.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its policy and procedure titled, Abuse & Mistreatment of Residents, which led to a situation where Resident 1 was hit by Resident 2, resulting in a swollen and red discoloration to the right eyelid of Resident 1. The policy required that when incidents involving the health, welfare, or safety of residents are reported, the involved resident(s) should be removed from the environment that threatened their health, welfare, or safety. However, this was not done, and both residents continued to share the same room despite the reported incidents. Resident 1, who had an intact cognition and was independent with personal hygiene and mobility, reported being hit by Resident 2 on multiple occasions. Resident 2, diagnosed with schizophrenia and on antipsychotic medication, had a care plan indicating episodes of striking out behavior. Despite these known issues, the facility did not separate the residents or update the care plan to prevent further incidents. Staff, including LVN 1 and CNA 1, were aware of the incidents but did not take appropriate actions such as documenting the incidents, notifying the physician and family, or creating a care plan with interventions to prevent further abuse. The Director of Nursing (DON) acknowledged that the residents should have been separated after the first incident to prevent further abuse. However, the DON was not informed of the initial incident and did not investigate it. The facility's failure to follow its own policies and procedures placed Resident 1 and potentially other residents at risk for further abuse, which could result in serious physical harm or injuries.
Failure to Timely Report Resident Abuse
Penalty
Summary
The facility failed to report alleged abuse incidents involving two residents to the California Department of Public Health (CDPH) within the required two-hour timeframe. On two separate occasions, one resident reported being physically assaulted by their roommate, resulting in visible injuries such as a red bruise and swollen eyelid. Despite these reports, the facility did not promptly notify the CDPH, delaying the investigation process. Resident 1, who was cognitively intact and capable of making decisions, reported being hit by Resident 2 on multiple occasions. The incidents were observed by staff, including a Certified Nurse Assistant (CNA) and a former Housekeeping Supervisor, who witnessed the altercations. Despite these observations and reports, the residents were not separated, and the facility's Director of Nursing (DON) was not informed in a timely manner. The facility's policy required that all allegations of abuse be reported to the CDPH within two hours. However, the DON misunderstood the reporting requirements, believing that a 24-hour window was permissible if there were no significant injuries. This misunderstanding, along with the failure to act on staff reports, resulted in a delay in addressing the abuse allegations and ensuring the safety of the residents involved.
Failure to Investigate Resident Altercation
Penalty
Summary
The facility failed to investigate a resident-to-resident altercation that occurred on 4/1/2024 between two residents, leading to a subsequent incident on 4/23/2024 where Resident 2 hit Resident 1 in the face, resulting in a red bruise and swelling on the right eyelid. Resident 1, who was cognitively intact and capable of making decisions, reported feeling unsafe sharing a room with Resident 2, who had a history of striking out behavior and was on antipsychotic medication for schizophrenia. Despite Resident 1's reports of being hit and feeling unsafe, the facility did not offer a room change or take adequate measures to separate the residents. Resident 2's care plan included monitoring and recording episodes of striking out behavior, yet there were six recorded episodes from 3/31/2024 to 4/2/2024, indicating a pattern of aggression that was not adequately addressed. The facility's staff, including a Licensed Vocational Nurse (LVN 1) and a Certified Nurse Assistant (CNA 1), were aware of the incidents but did not take appropriate action to separate the residents or ensure Resident 1's safety. The facility's Secretary confirmed that the incidents were reported to the Administrator and Director of Nurses, but no action was taken to move the residents to separate rooms. The Director of Nursing (DON) stated that the initial incident on 4/1/2024 was not reported to him, highlighting a breakdown in communication and reporting procedures within the facility. The facility's policy on abuse and mistreatment of residents required immediate investigation and reporting of all allegations, but this protocol was not followed. The Director of Staff Development emphasized the importance of reporting alleged abuse within two hours to ensure resident safety, yet this standard was not met, resulting in continued risk to Resident 1.
Failure to Implement Abuse Care Plan Leads to Repeated Incidents
Penalty
Summary
The facility failed to develop a comprehensive and resident-centered abuse care plan following two alleged physical abuse incidents involving two residents. On two separate occasions, one resident physically abused another, resulting in a red bruise and swelling on the victim's right eyelid. Despite the incidents being reported to the Director of Nursing (DON) and Administrator (ADM), no care plans were initiated to prevent further occurrences, and the residents were not separated to avoid further contact. Resident 1, who was cognitively intact and required supervision for certain activities, was repeatedly hit by Resident 2, who had a diagnosis of schizophrenia and was on antipsychotic medication. The facility's staff, including a Licensed Vocational Nurse (LVN) and a Certified Nurse Assistant (CNA), were aware of the incidents but did not take adequate steps to address the situation. The LVN failed to document a change of condition, implement interventions, or conduct a 72-hour monitoring period after the incidents, despite recognizing the importance of these actions. The facility's policy and procedure on abuse and mistreatment of residents required the initiation of a care plan to reflect current conditions and measures to prevent recurrence. However, this was not done, and the residents continued to share a room, increasing the risk of further abuse. The lack of a comprehensive care plan and failure to separate the residents contributed to the repeated abuse incidents.
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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