Extended Care Hospital Of Riverside
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, California.
- Location
- 8171 Magnolia Avenue, Riverside, California 92504
- CMS Provider Number
- 056162
- Inspections on file
- 36
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Extended Care Hospital Of Riverside during CMS and state inspections, most recent first.
The facility failed to prevent accident hazards and ensure adequate supervision and assistive devices for three residents. A resident who smoked was allowed to keep cigarettes and a lighter at bedside despite documented safety concerns and a policy requiring smoking materials to be maintained by staff, with no evidence of an IDT review or care plan addressing this. Another resident with impaired gait, no decision-making capacity, and identified fall risk required supervised transfers but had a known history of attempting independent transfers that CNAs did not report, and the care plan was not revised before the resident sustained an unwitnessed fall with facial injuries. A third resident with frequent falls and no decision-making capacity was found in bed yelling for help with the call light hanging out of reach, contrary to the care plan and facility policy requiring call lights to be accessible.
Two residents were involved in an incident where one flicked the other on the head, which was documented by staff but not reported to the state agency within the required two-hour timeframe. The delay in reporting was confirmed by the DON, and interviews revealed that some staff were unaware of the reporting requirements. The facility's policy required immediate reporting, but this protocol was not followed.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
A resident with impaired immunity and a history of UTI exhibited behavioral changes and refused medications and a physician-ordered urinalysis. Staff did not notify the physician of these changes or the treatment refusal until several days later, contrary to facility policy requiring prompt notification of significant changes in condition.
A resident with moderate cognitive impairment reported being scratched and having his arm twisted by his roommate, resulting in visible injuries. Although an LVN was informed of the incident and relayed it to the RN Supervisor, the allegation of abuse was not reported to CDPH within the required two-hour timeframe, as facility policy mandates. The Social Service Director became aware of the incident approximately eleven hours after it occurred, resulting in a delay in reporting.
A resident with documented bipolar and anxiety disorders was admitted after a PASARR Level I screening incorrectly indicated no serious mental illness. MDS nurses confirmed the mental health diagnoses were missed during the screening, which should have triggered a Level II evaluation prior to admission.
A resident with a history of a leg fracture and diabetes was discharged after improvement, but required post-discharge follow-up calls were not documented in the medical record. Interviews with the SSD and DON confirmed that facility policy mandates follow-up calls within 72 hours and again between 14-28 days post-discharge, but there was no evidence these were completed or recorded for the resident.
A facility failed to notify the LTC Ombudsman in a timely manner regarding a resident's discharge. The resident, diagnosed with esophageal cancer, was discharged to another facility with verbal consent. However, the required notice to the Ombudsman was sent four days late, contrary to the facility's policy that mandates prompt notification. This delay could potentially impact the resident's rights and discharge safety.
The facility failed to communicate decisions and rationales regarding issues raised by the Resident Council, leading to a deficiency in honoring residents' rights. Residents reported the dining room was closed at night, limiting access to the patio and vending machine. Staff interviews confirmed the closure, and the Administrator admitted solutions were not shared with the council, violating facility policy.
A resident with moderate cognitive impairment and a history of atelectasis was not assessed for self-administration of medication, despite expressing a desire to do so. The resident had a bottle of Robitussin, not ordered by the facility, visible on their nightstand. Staff interviews revealed a lack of awareness and action regarding the medication, and the facility's policy on self-administration was not followed.
A facility failed to update the PASARR for a resident after new diagnoses of depression and schizoaffective disorder. Initially, the resident had no active psychiatric disorders, but later assessments showed these new conditions. Despite the facility's policy requiring a new PASARR for newly diagnosed mental disorders, no additional screening was completed.
A resident was admitted with bipolar disorder and depression, but the PASARR Level I screening did not reflect these diagnoses, resulting in a negative screening and no Level II evaluation. The DON acknowledged the error, and the Administrator expected adherence to PASARR policy.
A resident with moderate cognitive impairment and physical limitations was not provided with necessary grooming and nail care assistance by the facility staff. Despite policies requiring routine grooming, the resident was observed with long toenails, fingernails, and facial hair. CNAs admitted to not having enough time to perform these tasks, and the DON and Administrator acknowledged the deficiency in care.
A resident with dysphagia was ordered to receive Isosource 1.5 tube feeding, but staff administered Fibersource HN instead, which has a lower caloric content. The LVN relied on a formula exchange sheet and previous day's formula bag, rather than verifying current orders. The RD confirmed the substitution was inappropriate, and the DON and Administrator expected staff to follow physician's orders.
A facility failed to properly store a nebulizer mask between uses for a resident, leading to a deficiency in respiratory care. The facility's policy requires nebulizer equipment to be cleaned, air-dried, and stored in a bag. However, observations revealed the mask was not stored in a bag as required. The resident, with a history of pneumonia, was receiving nebulizer treatments for shortness of breath. Interviews with staff confirmed the expectation to follow the facility's policy.
A resident with a history of low back pain and other conditions did not receive prescribed PRN pain medication despite requesting it before dialysis. The CNA informed the LVN of the request, but the LVN did not administer the medication, and there was no documentation of the medication being given. The facility's pain management policy was not followed.
The facility failed to ensure staff wore required PPE during care for residents on EBP. A resident with a gastrostomy tube and history of ESBL was cared for by an LVN who did not wear a gown during medication administration. Another resident with an ostomy and ESBL history received care from a CNA who did not wear a gown during bed linen changes and a bed bath. Both staff members acknowledged the oversight, and the DON confirmed the expectation for appropriate PPE use.
The facility failed to maintain room temperatures between 71 and 81 degrees Fahrenheit, affecting 46 residents. During an unannounced visit, temperatures in several rooms were observed to be between 82 and 85 degrees. A resident recovering from surgery and another with serious health conditions expressed discomfort due to the heat. The Maintenance Director reported a breaker fuse issue, and the facility's policy on temperature maintenance was not followed.
A facility failed to consistently monitor the weights of two residents upon admission, leading to significant weight changes without proper documentation or intervention. One resident experienced weight fluctuations with no record for the third week, while another resident had a significant weight loss with no documentation after the initial assessment. The registered dietician confirmed the lack of adherence to the facility's weight management policy, which required weekly monitoring and documentation for significant weight changes.
A resident reported that the hot water in his restroom took too long to heat, resulting in cold washcloths during bed baths. Multiple temperature checks confirmed that the water temperature did not reach the required range of 105 to 120 degrees Fahrenheit within a reasonable time frame. Interviews with staff corroborated the issue, and the facility's policy and relevant regulations highlighted the deficiency.
Failure to Prevent Accident Hazards, Falls, and Inaccessible Call Light
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and assistive devices for three residents. One resident who smoked was observed with cigarettes and a lighter at bedside, despite a smoking assessment documenting safety concerns such as burns to skin, clothing, furniture, and dropping ashes on self, with a recommendation to smoke only with supervision. Facility policy required smoking materials to be maintained by designated staff, and both an LVN and the ADON stated residents were not allowed to keep smoking paraphernalia at bedside without an IDT meeting, physician notification, and care plan in place. There was no documented evidence that such an IDT meeting, physician notification, or care plan had been completed for this resident, and staff were unaware the resident had cigarettes and a lighter at bedside. Another deficiency involved a resident at risk for falls who did not receive adequate supervision and effective fall prevention interventions. This resident had diagnoses including abnormalities of gait and mobility, was assessed as lacking capacity to understand and make decisions, and was identified as at risk for falls. The MDS indicated the resident required supervision or touching assistance for transfers. The resident experienced an unwitnessed fall while attempting to transfer, resulting in facial injuries and hospital transfer. CNAs reported the resident had a history of attempting to transfer independently from wheelchair to bed or toilet, that staff were aware of this behavior, and that one CNA had observed such behavior previously but did not report it to the licensed nurse. The ADON stated CNAs were expected to report unsupervised transfer attempts so that a fall risk assessment and care plan updates could be completed, but the care plan contained no revisions addressing the resident’s behavior of attempting to transfer independently prior to the fall. A third deficiency involved a resident at risk for falls whose call light was not within reach. The resident, who had diagnoses including frequent falls and lacked capacity to understand and make decisions, was heard yelling from her room and was found in bed with the call light hanging to the side of the bed and not within reach. The resident stated she wanted her bedside table moved and was unable to locate her call light. The resident’s care plan documented that the call light should be placed within reach and that the resident needed a prompt response to all requests for assistance. During observation and interview, an LVN confirmed the call light was not within reach and acknowledged that if the call light was not within reach, the resident would be unable to request assistance, including during an emergency. Facility policy required staff to ensure the call light is within reach of the resident and secured as needed.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of physical abuse involving two residents to the State survey agency within the required two-hour timeframe. One resident, who had dementia and was not capable of making decisions, was flicked on the head by another resident who had chronic obstructive pulmonary disease, polyneuropathy, and depression. The incident was documented in the progress notes, with the aggressor admitting to flicking the other resident on the head to quiet him. There were no witnesses to the event, and the resident who was flicked did not sustain any injuries. Despite the documentation of the incident in the medical record, there was no evidence that the alleged abuse was reported to the California Department of Public Health within two hours as required. The Director of Nursing confirmed that the incident was not reported until seven days after it occurred, after being notified by the Social Service Director who discovered the documentation during a routine review. Interviews with nursing staff revealed a lack of awareness regarding the two-hour reporting requirement for allegations of abuse. The facility's policy required immediate reporting of all alleged violations to the appropriate agencies, specifying a two-hour window in cases of serious bodily injury. However, the staff involved did not follow this protocol, resulting in a delay in notifying the authorities about the incident. The failure to report the allegation in a timely manner was confirmed through interviews, record reviews, and observation.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Notify Physician of Resident's Change in Condition and Treatment Refusal
Penalty
Summary
The facility failed to notify the physician of a significant change in condition and refusal of treatment for one resident. The resident, who had diagnoses including toxic encephalopathy and a urinary tract infection (UTI), exhibited behavioral changes and refused medications, blood sugar checks, and a physician-ordered urinalysis. Documentation shows that on June 16, the resident refused care and displayed aggressive behaviors, but there was no evidence that the physician was notified of these changes or the refusal to complete the urinalysis at that time. Physician notification did not occur until four days later, despite ongoing noncompliance and worsening behavior. Facility staff interviews confirmed that the refusal and behavioral changes should have been reported to the physician and documented in the medical record, in accordance with facility policy. The lack of timely physician notification and documentation was identified through observation, interview, and record review.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe after the allegation was made. A resident with moderate cognitive impairment and a history of osteomyelitis reported an altercation with his roommate, during which he claimed his arm was twisted and he was scratched, resulting in visible scabbed marks above his wrist. The incident was documented in a social service progress note, and the resident expressed feeling unsafe that night. The roommate confirmed there was a heated exchange but denied physical contact, while a Licensed Vocational Nurse (LVN) stated she was informed by the resident that he had been scratched and reported this to the RN Supervisor, instructing her to notify the DON. Despite the facility's policy requiring all alleged violations to be reported immediately, but no later than two hours after the allegation is made, the Social Service Director became aware of the incident approximately eleven hours after it occurred. The administrator confirmed that abuse allegations should be reported to CDPH within two hours, but this protocol was not followed in this case. The delay in reporting the incident constituted a failure to comply with regulatory requirements for timely reporting of suspected abuse.
PASARR Screening Failed to Identify Resident's Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I screening accurately reflected the presence of diagnosed mental disorders for a resident. Specifically, a resident was admitted with diagnoses including bipolar disorder and anxiety disorder, but the PASARR Level I screening was marked as negative for serious mental illness (SMI). The screening form incorrectly indicated that the resident did not have a serious diagnosed mental disorder, despite documentation of such diagnoses in the admission record. During interviews and record reviews, it was confirmed by two Minimum Data Set Nurses (MDSNs) that the mental health diagnoses were missed during the PASARR screening process. One nurse acknowledged that the question regarding serious mental illness should have been answered affirmatively, and both nurses recognized that this error could have changed the PASARR result from Level I Negative to Level I Positive, which would have required further evaluation prior to admission. The facility's policy states that a positive Level I screen necessitates a Level II evaluation before admission.
Failure to Document Post-Discharge Follow-Up
Penalty
Summary
The facility failed to ensure that a post-discharge follow-up was conducted and documented in the medical record for one resident. The resident, who had a history of a left tibia fracture and type 2 diabetes mellitus, was admitted to the facility and later discharged after his health improved. Documentation review showed that there was no evidence of a follow-up call or contact with the resident after discharge, as required by facility policy. The Social Service Director confirmed that follow-up calls should be made within 72 hours post-discharge and that records of such calls are maintained, but was unable to confirm whether the case manager completed this for the resident in question. Further interviews with the Director of Nursing revealed that both social services and case management are responsible for conducting and documenting follow-up calls at specific intervals after discharge. Review of facility policies confirmed the requirement for timely follow-up calls and accurate documentation in the medical record. However, there was no documentation indicating that the required post-discharge follow-up was completed for the resident, resulting in a deficiency related to discharge planning and documentation.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure timely notification to the Office of the State Long-Term Care Ombudsman regarding the proposed transfer or discharge of a resident. Specifically, the facility did not notify the Ombudsman until four days after the resident had been discharged. The resident, who had been admitted with a diagnosis of esophageal cancer, was discharged to another facility. Although the resident had given verbal consent to the discharge plan, the Social Services Director (SSD) did not send the required notice to the Ombudsman on the day the resident received the discharge notice. The facility's policy requires that the notice of transfer or discharge be provided to the resident and the LTC Ombudsman as soon as practicable before the transfer or discharge. However, the SSD admitted to not following this protocol, as there was no evidence that the Ombudsman was notified on the appropriate date. This oversight could potentially result in the resident lacking an advocate to protect their rights and ensure an appropriate and safe discharge plan.
Failure to Communicate Resident Council Decisions
Penalty
Summary
The facility failed to ensure that staff discussed decisions and rationales regarding issues raised by the Resident Council, which led to a deficiency in honoring residents' rights to organize and participate in resident/family groups. Interviews with residents revealed that the dining room, which provides access to the patio and vending machine, was closed at night, limiting their ability to socialize, relax, and access amenities. Despite residents expressing concerns about the dining room's closure during Resident Council meetings, the facility did not communicate the solutions or their rationale to the council. Interviews with staff, including a CNA, Dietary Service Supervisor, and the Registered Nurse Supervisor, confirmed the dining room was locked at night, contrary to the Assistant Director of Nursing's statement that it should only be closed. The Administrator acknowledged that while solutions were developed to address the issue, they were not shared with the Resident Council. The facility's policy requires that decisions be communicated to the council, which was not adhered to in this case. The residents involved were capable of making decisions, as indicated by their medical records.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, despite the resident expressing a desire to do so. The facility's policy supports residents' rights to self-administer medications, contingent upon an interdisciplinary team assessment to ensure safety. However, the resident, who had a moderate cognitive impairment and a medical history of atelectasis, was not assessed for self-administration. The resident had a bottle of Robitussin, brought by a family member, visible on their nightstand, which was not ordered by the facility and was not included in the resident's medication orders. Interviews with staff revealed a lack of awareness and action regarding the presence of the medication at the resident's bedside. CNAs and an LVN were unaware of the medication, and the LVN confirmed that no assessment for self-administration had been conducted. The Director of Nursing and the Administrator both stated that no residents were approved for self-administration of medications, and the presence of the medication should have been reported and assessed according to facility policy. The oversight resulted in a failure to adhere to the facility's policy on medication self-administration.
Failure to Update PASARR Following New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a new Preadmission Screening and Resident Review (PASARR) for a resident following the diagnosis of new mental disorders. The resident was admitted with no active psychiatric or mood disorders, as indicated by the initial PASARR Level I screening. However, subsequent assessments revealed the resident was diagnosed with depression and schizoaffective disorder. Despite these new diagnoses, the facility did not complete an additional PASARR Level I screening as required by their policy. Interviews with the Director of Nursing and the Administrator confirmed that a new PASARR should have been completed following the resident's new mental health diagnoses. The facility's policy mandates that any resident exhibiting a newly evident or possible serious mental disorder should be referred for a Level II resident review. The failure to adhere to this policy resulted in the deficiency noted in the report.
Inaccurate PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I screening accurately reflected the presence of diagnosed mental disorders for a resident. The resident was admitted with a medical history that included unspecified bipolar disorder and depression, but the PASARR Level I screening completed by a local hospital did not reflect these diagnoses. As a result, the screening was marked as negative, and a Level II evaluation was not conducted. Interviews with facility staff revealed that the MDS Coordinator and the Director of Nursing (DON) were responsible for reviewing PASARR screenings for accuracy. The DON acknowledged that the PASARR for the resident was inaccurate and should have been corrected. The Administrator expected staff to adhere to the facility's policy for PASARRs, which was not followed in this instance, leading to the deficiency.
Failure to Assist Resident with Grooming and Nail Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required substantial assistance due to moderate cognitive impairment and physical limitations following a stroke. The resident, who had hemiplegia and hemiparesis affecting one side of the body, was observed with long toenails, fingernails, and facial hair, indicating a lack of grooming and nail care. Despite the facility's policies requiring routine grooming and nail care, the staff did not assist the resident adequately, leaving the resident with untrimmed nails and unshaven facial hair. Interviews with Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) revealed that the CNAs were responsible for grooming tasks, but they failed to perform these duties due to time constraints. The CNAs admitted to not having enough time to shave the resident or trim their nails, and one CNA did not report the resident's long toenails to anyone. The Director of Nursing (DON) and the Administrator confirmed that it was unacceptable for staff to neglect these tasks and expected residents to be groomed as needed. The resident expressed discomfort due to the condition of their toenails, further highlighting the deficiency in care provided by the facility.
Failure to Administer Correct Tube Feeding Formula
Penalty
Summary
The facility failed to provide the correct tube feeding formula as ordered for a resident, leading to a potential nutritional deficiency. The resident, who had a history of dysphagia following a stroke and was receiving nutrition via a feeding tube, was ordered to receive Isosource 1.5 at a rate of 60 mL per hour for 16 hours daily. However, staff provided Fibersource HN instead, which has a lower caloric content, potentially leading to insufficient caloric intake. Observations revealed that the incorrect formula was administered on multiple occasions, and the staff responsible for the resident's care did not follow the updated physician's orders. The Licensed Vocational Nurse (LVN) involved relied on a formula exchange sheet and the previous day's formula bag, rather than verifying the current orders. The Registered Dietitian (RD) confirmed that the substitution was not appropriate and that she had not been consulted about the change. Interviews with the Director of Nursing (DON) and the Administrator indicated that staff were expected to follow physician's orders and consult the RD or physician if the ordered formula was unavailable. Despite these expectations, the LVN did not verify the updated orders, leading to the administration of an incorrect formula, which was not a comparable exchange for the ordered Isosource 1.5.
Improper Storage of Nebulizer Mask
Penalty
Summary
The facility failed to properly store a nebulizer mask between uses for a resident, leading to a deficiency in respiratory care. The facility's policy on nebulizer therapy, revised in February 2024, specifies that nebulizer equipment should be cleaned after each use, disassembled, rinsed with sterile or distilled water, air-dried, and stored in a storage bag once completely dry. However, observations on December 16 and 17, 2024, revealed that the nebulizer mask for Resident #7 was not stored in a bag as required by the policy. Instead, it was found lying on top of the resident's dresser. Resident #7, who was admitted to the facility in November 2024, had a medical history that included pneumonia and was receiving as-needed nebulizer treatments for shortness of breath related to a cough. The resident's care plan included the administration of DuoNeb as ordered. Interviews with LVN #3 and the Director of Nursing confirmed that the nebulizer mask should be stored in a bag when not in use, aligning with the facility's policy. The Administrator also expressed the expectation that staff follow the facility's policy regarding the cleaning and storage of nebulizer masks.
Failure to Administer PRN Pain Medication
Penalty
Summary
The facility failed to provide appropriate pain management for Resident #210, who had a medical history of low back pain, personal history of malignant neoplasm of the breast, and acute kidney failure. The resident was admitted on 12/11/2024 and had orders for Tylenol and Norco for pain management. On 12/16/2024, the resident reported a pain level of 7 out of 10 and requested pain medication before going to dialysis. Despite this request, there was no documented evidence that the resident received the prescribed PRN Tylenol or Norco on that day. The deficiency occurred when CNA #6, after being informed by the resident about the need for pain medication, communicated this to LVN #7. However, LVN #7 could not recall if he was informed about the request and admitted to not administering the pain medication before the resident's dialysis session. The facility's policy on pain management, which requires recognizing and managing pain consistent with the resident's care plan and preferences, was not followed, as confirmed by the Administrator's statement that the medication should have been given upon the resident's complaint of pain.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore all required personal protective equipment (PPE) during the provision of care for residents on enhanced barrier precautions (EBP). This deficiency was observed in the care of Resident #18, who had a history of extended-spectrum beta-lactamase (ESBL) and utilized a gastrostomy tube. During a medication administration task, a Licensed Vocational Nurse (LVN) checked the resident's vital signs and administered medications via the feeding tube while wearing gloves but not a gown, contrary to the facility's policy. The LVN admitted to not knowing that a gown was required for such procedures. Similarly, the facility's failure to adhere to EBP was noted in the care of Resident #5, who also had a history of ESBL and an ostomy. A Certified Nursing Assistant (CNA) changed the resident's bed linens and provided a bed bath while wearing a mask and gloves but no gown. The CNA acknowledged that a gown should have been worn due to the resident's EBP status. The Director of Nursing confirmed that the expectation was for staff to wear appropriate PPE, including gowns, when providing care to residents on EBP.
Failure to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents by not ensuring room temperatures were kept between 71 and 81 degrees Fahrenheit. During an unannounced visit, it was observed that the temperatures in several rooms ranged from 82 to 85 degrees Fahrenheit, affecting 46 out of 96 residents. The Maintenance Director reported that a breaker fuse had gone bad, causing the generator power to activate, and they had been working on replacing the fuse throughout the day. Two residents were interviewed during the visit. One resident, who was recovering from surgery, was observed perspiring and expressed discomfort due to the heat. Another resident, who had multiple serious health conditions including acute respiratory failure and chronic congestive heart failure, also expressed discomfort and dissatisfaction with the situation. The facility's policy on maintaining temperatures within the specified range was not adhered to, leading to the substantiated complaint of an uncomfortable environment for the residents.
Failure to Monitor Resident Weights Consistently
Penalty
Summary
The facility failed to weigh two residents, Resident A and Resident B, on admission and weekly for the first four weeks as required to establish a baseline weight. This failure was identified during an unannounced visit on June 10, 2024, for an allegation of quality of care and treatment. Resident A, who was admitted with diagnoses including Type II Diabetes Mellitus, Sepsis, and Alzheimer's, experienced significant weight fluctuations without consistent monitoring. Initial weight was recorded at 173 pounds, followed by a loss to 166 pounds and then 160 pounds, with no weight documented for the third week. The registered dietician (RD) confirmed that the policy required weekly weights for the first four weeks and noted that a 5% weight change in a week is significant and requires closer monitoring. Resident B, admitted with a history of falls and a heart attack, also experienced significant weight loss without consistent monitoring. Initial weight was 118 pounds, dropping to 109 pounds within a week, and further to 103 pounds over the following weeks. The RD noted that a nutritional assessment should be completed within the first two weeks of admission, and progress notes should be added for any weight changes. However, there was no documentation of weight or nutritional progress notes for Resident B after February 7, 2024, despite continued weight loss. The facility's policy on weight management, dated December 19, 2022, outlined the need for a systematic approach to optimize residents' nutritional status, including weekly weight monitoring for newly admitted residents. The policy also required the RD to document weight change notes for significant weight changes. The RD acknowledged the lack of documentation and monitoring for both residents, which was inconsistent with the facility's policy and professional standards of practice.
Failure to Maintain Appropriate Water Temperatures
Penalty
Summary
The facility failed to ensure that the resident's water temperatures were maintained at a comfortable level, as evidenced by the complaint from Resident 1 and subsequent observations. Resident 1, who has a medical history including malignant neoplasm of the lung, secondary malignant neoplasm of the brain, type 2 diabetes mellitus, and atrial fibrillation, reported that the hot water in his restroom took too long to heat, resulting in cold washcloths during bed baths. Multiple temperature checks confirmed that the water temperature in Resident 1's restroom did not reach the required range of 105 to 120 degrees Fahrenheit within a reasonable time frame, with temperatures recorded at 85, 95, 89.5, and 100.6 degrees Fahrenheit at various times during the surveyor's visit. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Maintenance Director (MD), corroborated the issue, with the MD acknowledging that the water temperature should not take more than five minutes to heat up. The Director of Nursing (DON) also confirmed that the hot water was taking an unusually long time to reach the appropriate temperature. A review of the facility's policy on safe water temperatures and relevant California Code Regulations further highlighted the deficiency, as the facility failed to maintain hot water temperatures within the required range for resident care areas.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
