Griffith Park Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, California.
- Location
- 201 Allen Ave., Glendale, California 91201
- CMS Provider Number
- 056111
- Inspections on file
- 62
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 39 (1 serious)
Citation history
Health deficiencies cited at Griffith Park Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, protein-calorie malnutrition, and a G-tube had physician orders for enteral feeding with Jevity 1.2 via pump, but no corresponding care plan was developed or implemented to address G-tube use or care. The MDS documented moderately impaired cognition and the presence of a feeding tube, yet review of the care plans showed no interventions or goals related to G-tube management. During interviews, the DON and QAN acknowledged that care plans are essential to guide staff and monitor care, and facility policy required a comprehensive, person-centered care plan with measurable objectives and timetables for each resident within a specified timeframe, which was not done for this resident’s G-tube.
A resident with significant cardiac history and a POLST indicating full code status became weak, developed shallow breathing, stopped talking, and became unresponsive after dinner. CNAs summoned nursing staff, but the RN focused on obtaining vital signs and verifying code status, left the resident sitting upright, and did not initiate CPR, citing a pain response as evidence of responsiveness. An LVN recognized abnormal breathing and the need to call 911 but did not start CPR, and another LVN was unaware that ventilation should be provided to an unresponsive resident with slow breathing; no staff performed chest compressions before EMS arrival. The crash cart contained only 8 L/min oxygen regulators, preventing proper BVM use at 15 L/min, and the RN could not determine that the oxygen tank was empty or correctly connect the suction machine. EMS arrived to find the resident pulseless, apneic, in asystole, and with no CPR in progress, leading surveyors to cite a deficiency for failure to provide immediate, effective BLS and CPR to a full-code resident.
A resident with severe cognitive impairment, multiple cardiac diagnoses, and full code status experienced respiratory distress and became unresponsive, but nursing staff failed to provide competent emergency care in accordance with facility policies. An RN could not determine that the crash cart oxygen tank was empty, did not know how to connect the suction machine, and could not state that a backboard was needed for CPR; competency records showed no evaluation for suction use, vital signs, or emergency response. An LVN reported the resident became weak and was breathing slowly, but did not initiate ventilation, was unable to document vital signs, and paramedics found that staff were not performing CPR, no backboard was in place, and the oxygen regulator delivered only up to 8 L/min. Facility policies required prompt assessment and intervention for respiratory and cardiac symptoms, immediate CPR by trained licensed staff when an individual is unresponsive and not breathing normally, and accurate documentation, as well as sufficient, competent nursing staff, which were not met in this event.
A resident with a documented history of schizophrenia, depression, anxiety, suicidal ideation, and impaired impulse control was admitted from a hospital without the LTC staff thoroughly reviewing or incorporating the hospital’s psychiatric records into the initial psychosocial assessment, baseline care plan, or IDT discussion. Social services left key psychosocial risk areas blank, and nursing staff did not clarify reported aggressive behavior, did not fully assess behavioral needs, and did not implement a behavior management care plan or timely psychiatric evaluation. Within days of admission, while pacing the hallway before a smoke break, the resident suddenly struck another resident seated in a wheelchair on the upper back with an open-hand slap, as witnessed by multiple staff, and later stated not knowing why the act occurred.
A resident with bilateral blindness, respiratory failure, and diabetes, who was cognitively intact and required moderate assistance with ADLs, did not have a comprehensive, person-centered care plan addressing visual impairment. The resident reported relying on touch and temperature to identify food, and nursing staff stated that assistance was usually provided with meal set-up, transfers, and toileting due to blindness. However, record review with nursing staff and the MDS nurse confirmed that no care plan had been initiated for the resident’s blindness, contrary to facility policy requiring measurable objectives and timetables for each resident’s physical, psychosocial, and functional needs.
A resident with chronic respiratory failure and COPD receiving continuous oxygen via nasal cannula was found to have oxygen tubing that was not labeled with the date it was last changed and nebulizer tubing that had not been changed within the required 7-day interval. During observations and interviews, an LVN and an RN acknowledged that oxygen tubing must be dated and changed weekly and that nebulizer tubing should be changed every 7 days to prevent infection, but there was no documentation in the medical record of the date and time of oxygen set-up or respiratory therapy. Review of facility policies confirmed requirements to change oxygen cannula and tubing every 7 days and to document the date and time of these procedures, which were not followed for this resident.
Three residents who required assistance with ADLs and incontinence care experienced prolonged delays in staff response to call lights, contrary to facility policy requiring responses within minutes. One resident, who was bedbound with severe cognitive impairment and total incontinence, reported waiting about an hour in wet and soiled briefs after using the call light, and a family member corroborated long waits and frequent unanswered call bells. Another resident with moderately impaired cognition, frequent incontinence, and mobility limitations reported waiting one to two hours for adult brief changes, and was observed in a wheelchair while the call light was placed on the bed out of reach. A third resident with hemiplegia and intact cognition, on a toileting program and needing substantial assistance, stated he routinely waited at least an hour after activating the room or bathroom call light for toileting and cleaning, and was also observed with the call light out of reach. Staff, including an LVN and the DSD, acknowledged that call lights should be within reach and answered promptly, but this did not occur, placing residents at risk for infection, skin breakdown, and discomfort.
A resident with severe cognitive impairment, dental problems, and new facial swelling developed toothache pain, and the MD ordered PRN Orajel along with existing PRN acetaminophen and shift pain monitoring. For three days, the MAR showed no administration of Orajel or acetaminophen and documented that the resident denied pain, while family repeatedly reported mouth pain and difficulty eating and were told the medication had not arrived. The resident later described pain at 8/10 and needing to chew on the opposite side, and the DSD confirmed the Orajel was ordered but not given for three days and that no thorough pain assessments were documented, contrary to the facility’s pain protocol.
A resident with open facial wounds and a history of squamous cell carcinoma did not receive appropriate pain management during wound care. Staff failed to consistently assess and document pain before, during, and after treatments, and did not always offer or administer prescribed pain medications. The resident exhibited both verbal and non-verbal signs of pain, and refusals of care due to pain were not properly communicated to the physician, as required by facility policy.
A resident with advanced skin cancer, wounds, and dementia experienced a breakdown in communication and collaboration among the Attending Physician, Wound Care Specialist, Dermatologist, and Oncologist. Gaps in documentation, unclear physician responsibility, and inconsistent care planning led to confusion among nursing staff about who was managing the resident's wound and pain care.
Two residents were involved in a physical altercation resulting in injury, but staff and the Administrator failed to report the incident to authorities, did not document the event in clinical records, and did not update care plans as required by facility policy. Both residents had cognitive impairments, and the lack of action left them unprotected and the incident uninvestigated.
Two residents with severe cognitive impairment were involved in an altercation resulting in one sustaining a visible injury. Despite staff awareness and documentation of the incident, the administrator instructed staff not to report the event, leading to a failure to notify authorities, responsible parties, or document the incident in the medical record, in violation of facility policy and state regulations.
A resident with multiple pressure injuries and significant care needs did not receive the required weekly wound assessments and documentation by the wound doctor or treatment nurse, as outlined in the care plan. Facility staff failed to inform the wound doctor and did not document initial or ongoing wound evaluations, despite facility policies mandating regular assessment and documentation for pressure injury management.
A resident with multiple health conditions, including delusional disorder and severe visual impairment, was found with several bottles of vitamin supplements at bedside and reported self-administering them. Staff interviews and record review revealed that the IDT had not assessed the resident's ability to safely self-administer medications, nor was there a physician's order or documentation as required by facility policy. Nursing staff were unaware of the supplements, and no evaluation or oversight was in place for the resident's self-administration of medications.
A resident with severe visual impairment and delusional disorder did not receive a comprehensive assessment within the required 14 days after admission, resulting in the absence of a care plan for her blindness. The resident expressed frustration with her care, and staff were uncertain how to address her needs due to the delayed MDS assessment.
A resident admitted with MASD and identified as high risk for pressure injury did not receive required weekly skin assessments as outlined in facility policy. Despite care plan interventions and the need for ongoing monitoring, staff confirmed that weekly assessments were missed, and documentation was lacking.
A resident with a history of major depressive disorder, anxiety, and schizophrenia exhibited escalating behavioral symptoms, including agitation, repeated requests for hospital transfer, and self-harm behaviors. Facility staff did not implement 1:1 supervision, failed to notify the physician of the resident's complaints and behavioral changes, and did not provide additional interventions or adequate monitoring. The situation escalated to the resident breaking a window and threatening self-harm, resulting in emergency transfer to a hospital.
A resident with cognitive impairment and a history of schizoaffective disorder physically and verbally abused another resident following a dispute. Although staff initially separated the two, the aggressor was able to return to the shared room due to inadequate supervision and communication, resulting in further threats and distress for the victim. The incident was not fully documented, and the facility's abuse prevention policy was not effectively implemented.
A resident with multiple chronic conditions was transferred to a GACH for psychiatric evaluation, and although a 7-day bed hold was ordered, neither the resident nor their responsible party received written information about the facility's bed hold policy at the time of transfer or within 24 hours, as required by facility policy. Interviews and record review confirmed the lack of notification and documentation.
A resident with diagnoses of bipolar disorder, depression, hemiplegia, and seizures did not have a person-centered care plan addressing their behavioral health needs or the use of medications such as Lexapro and Risperidone. The DON confirmed that care plans did not include interventions for these conditions, despite facility policy requiring comprehensive, updated care plans based on assessment findings.
A facility failed to implement its abuse prevention and reporting policies after a resident had a verbal altercation with an LVN. The incident was not investigated, and the LVN was not suspended, allowing further contact with the resident. The resident, who had intact cognition and required moderate assistance, called the police, but the facility did not document any investigation or interviews with the resident or witnesses. This failure placed residents at risk for potential abuse.
A resident in an LTC facility alleged verbal abuse by an LVN, prompting a police visit. Despite the facility's policy requiring immediate reporting of abuse allegations, staff failed to notify the State Survey Agency within the required timeframe. The resident, with intact cognition and a history of behavioral symptoms, accused the LVN of making threats. Interviews revealed that the DON and ADM were not informed, and staff did not adhere to mandated reporting duties.
The facility failed to implement its smoking policy, leading to unsupervised smoking and storage of smoking materials by residents, creating accident hazards. Residents were not adequately supervised, and some were allowed to smoke during nonscheduled times, posing risks of burns and fire hazards.
The facility failed to include POLST forms in the clinical records of three residents, potentially hindering access to their healthcare preferences during emergencies. Additionally, a resident's POLST and Advance Directive acknowledgment forms were missing, leading to uncertainty about their healthcare decisions. The facility's policies require these documents to be signed and filed appropriately, but this was not followed.
A resident with paraplegia and osteoarthritis refused podiatric care for long, infected toenails, but the facility failed to develop a care plan or conduct an interdisciplinary team meeting to address the refusal. The staff did not assess the reason for refusal or explain the risks, contrary to facility policy.
The facility failed to provide sufficient staffing to supervise residents during smoking times and monitor those at risk of elopement. Observations showed residents smoking without supervision, and staff interviews confirmed that short staffing prevented adequate monitoring. The DON acknowledged the staffing issues, which contradicted the facility's policy on providing sufficient nursing staff.
The facility failed to properly store medications for several residents, including Insulin Glargine and Lorazepam, leading to potential issues with medication integrity and security. Insulin pens were found in a refrigerator with water dripping from a melting freezer, and Lorazepam was stored at incorrect temperatures and not locked separately as required. These deficiencies could affect medication efficacy and security.
The facility failed to maintain proper sanitation and temperature logs in the kitchen, with missing entries in the sanitization sink solution, cold storage temperature, and sanitizer solution logs. This lack of documentation indicates non-compliance with the facility's policies, potentially risking food safety.
The facility failed to follow infection control practices by not disinfecting a blood pressure cuff and monitor between uses on two residents. Additionally, the facility lacked proper documentation and monitoring of its water system for Legionella, as required by its policies. These deficiencies were identified through observations and interviews with staff.
The facility failed to maintain an effective pest control program, resulting in a live cockroach being found in the supply room with enteral nutrition. The pest control service did not inspect or treat the storage rooms, and the facility's policies on pest control were not effectively implemented.
A resident in an LTC facility did not have the administration of Morphine Sulfate documented on the Control Drug Record, as required by facility policy. Additionally, there were discrepancies in the documentation of the physician's order and the volume of the medication vial. The RN and DON confirmed these errors, which could lead to medication errors and potential diversion.
A resident with diabetes and cellulitis was found wearing unsafe duct-taped slippers instead of a post-op shoe, increasing fall risk. The resident's family modified the slippers due to missing post-op shoes, but staff failed to assess and provide appropriate footwear, contrary to facility policies.
A resident at risk for pressure injuries had their low air loss mattress incorrectly set for a weight of 320 lbs instead of 200 lbs, despite weighing 185 lbs. This oversight, observed during an inspection, increased the risk of skin breakdown. The resident had severe cognitive impairment and required significant assistance with daily activities. The facility's policy required regular monitoring of mattress settings, which was not followed, leading to this deficiency.
A resident with paraplegia and osteoarthritis did not receive necessary foot care due to a failure in communication and follow-up by the facility staff. Despite having a physician's order for podiatry care, the resident's refusal was not properly assessed, and no alternative care was provided, resulting in pain and discomfort from long toenails.
A resident with dementia and malnutrition was incorrectly administered Peptamen AF instead of the physician-ordered Peptamen [NAME] PHGG via GT feeding. The RD confirmed the formulas are different, and the RN mistakenly believed they were the same. The DON acknowledged the error, emphasizing the need for a new physician order when using an alternative formula.
A resident's nebulizer mask was not stored in a plastic bag when not in use, contrary to the facility's policy and professional standards. This oversight was observed during a room inspection and confirmed by the Infection Prevention Nurse. The resident, who had a lung disorder and required nebulizer treatment, was at risk of equipment contamination due to this deficiency.
A LTC facility failed to properly manage and document the handling of Morphine Sulfate (MS) for a resident, leading to discrepancies in medication destruction and administration records. The facility did not discard the remaining MS after discontinuation, failed to document its administration on the Control Drug Record, and did not maintain accurate records of MS received from the hospice pharmacy. Additionally, nurses did not consistently sign the Narcotic Medications Surveillance log, indicating incomplete narcotic counts.
A resident with moderate protein-calorie malnutrition and GERD was served meals containing tomato products and milk, despite her stated dislikes and allergy. The facility's process for checking diet cards failed, resulting in the resident receiving inappropriate food items.
The facility's QAA committee failed to implement policies for smoking policy noncompliance, resulting in eight residents smoking unsupervised during nonscheduled times. The DON, acting as Administrator, acknowledged the absence of a policy, and staff reported being unable to enforce compliance. The deficiency was identified through observations and interviews, highlighting the lack of oversight and input from the Activity Director.
A facility failed to maintain a functioning call light system for a resident with severe cognitive impairment and multiple health issues, as observed during a survey. The resident required extensive assistance for daily activities, and the absence of a call light was acknowledged by staff as unacceptable, violating the facility's policy.
The facility failed to maintain a clean environment, as a resident's oxygen concentrator was dusty and flies were present in the dining room. Staff acknowledged the issues, but the problems persisted, with residents expressing concerns about flies for two months. The facility's policies on pest control and cleanliness were not followed.
The facility was found non-compliant with federal regulations by accommodating more than four residents in five rooms, each containing six beds. Despite residents not expressing concerns about space, the facility's policy stated rooms should accommodate no more than two residents. The DON acknowledged the issue and mentioned a Room Variance Waiver was in place, with plans to request an additional waiver.
The facility failed to provide the required minimum of 80 square feet per resident in five rooms, as identified during an interview with the DON. Despite the deficiency, residents did not express concerns about the limited space and were observed moving around comfortably. The facility's analysis confirmed these rooms provided only 72.33 square feet per resident, below the required standard.
A resident with severe cognitive impairment eloped from the facility due to inadequate assessment and supervision. Despite exhibiting wandering behavior, the resident was not identified as at risk for elopement, and no care plan was developed. Staff failed to announce the emergency code for a missing resident, delaying the response. The facility did not follow its policies for managing residents at risk for elopement, leading to the resident's disappearance and an Immediate Jeopardy situation.
A resident with severe cognitive impairment and a history of wandering eloped from a facility due to staff's lack of competency in managing elopement risks. The LVN did not attend necessary in-service training, and the DSD failed to evaluate staff competencies. The resident's Elopement Evaluation form was incorrectly filled out, and no care plan was developed to prevent wandering. Staff panicked and did not follow procedures, such as announcing Code Green, delaying the search and notification process.
A resident was inappropriately discharged from an LTC facility to law enforcement and then to family without a physician's order or proper discharge planning. The resident, who required assistance with daily activities and had multiple medical diagnoses, did not receive prescribed medications for six days. Facility staff failed to communicate effectively or follow established discharge procedures, leading to a lack of coordination and planning for the resident's safe transfer.
A resident with schizophrenia and anxiety disorder refused Risperidone, an antipsychotic medication, upon admission to an LTC facility. Despite a physician's order, the medication was not administered for several days due to the resident's refusal. The care plan did not address this refusal, focusing instead on other non-compliance issues. Interviews with staff confirmed the lack of a tailored care plan for the medication refusal, contrary to facility policy.
A resident with schizophrenia was not monitored for specific behaviors as required by the facility's policy, leading to a potential delay in physician notification and treatment. The resident was prescribed Risperidone, but staff interviews revealed that behavior monitoring was not conducted from admission until several days later, despite the facility's protocol. The DON acknowledged the oversight.
Failure to Develop and Implement G-Tube Care Plan for Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, resident-specific care plan for a resident with a gastrostomy tube (G-tube). The resident’s admission record showed readmission with unspecified protein-calorie malnutrition, unspecified dementia, and gastrostomy status. The resident’s MDS dated 3/3/2026 documented moderately impaired cognitive skills for daily decision-making and the presence of a feeding tube. The physician’s order summary dated 10/02/2025 included an enteral feeding order specifying Jevity 1.2 at 50 ml per hour for 20 hours via pump, with instructions to provide 1000 ml per 1200 calories in 24 hours, off at 8 AM and on at 12 PM or until dose limit. Despite these documented conditions and orders, review of the resident’s care plans revealed no care plan initiated that addressed the use of or care for the resident’s G-tube. During interviews, the DON stated that it was important to have a care plan for each resident to ensure goals are met and that care plans are revised as needed to meet resident-specific goals, and further stated that the care plan helps monitor resident care and guide staff in providing care. In the same interview, the QAN stated that the purpose of a care plan is to have specific goals and interventions so staff know how to care for the resident. The facility’s policy titled “Care Plans, Comprehensive Person-Centered,” dated 3/2022, required development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables for each resident within seven days of completion of the required MDS and no more than 21 days after admission, which was not followed for this resident’s G-tube care.
Failure to Initiate Immediate CPR and Provide Adequate BLS and Oxygen Equipment for a Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide proper and effective Basic Life Support (BLS), including immediate CPR, to a resident who was documented as full code. The resident had multiple cardiac-related diagnoses, including diabetes mellitus, congestive heart failure, dementia, atrial fibrillation, and atherosclerotic heart disease, and a POLST indicating that resuscitation/CPR should be attempted with full treatment status. The resident’s care plan identified potential for cardiac distress and directed staff to monitor for symptoms such as dyspnea, shortness of breath, tachycardia, edema, and to promptly contact the physician if symptoms occurred. On the day of the event, the resident had been stable earlier and ate 100% of dinner, but later became weak, had shallow breathing, stopped talking, and became unresponsive. When the change in condition occurred, CNAs observed the resident become unresponsive with eyes rolling back and immediately summoned nursing staff. RN 1 responded and found the resident sitting up at approximately a 70–90 degree angle, unresponsive, with shallow breathing and not verbally responsive, but making noises. RN 1 proceeded to obtain vital signs and reported normal blood pressure, heart rate, respiratory rate, and oxygen saturation initially at 98%, later dropping to 96% and then 89%. Instead of immediately initiating CPR or placing the resident supine on a firm, flat surface with a head-tilt, chin-lift to open the airway, RN 1 left the room to verify code status and retrieve the crash cart. RN 1 stated he did not initiate CPR because the resident made a noise in response to painful stimulation of the ear and he believed this indicated responsiveness. Staff did not initiate chest compressions while the resident remained unresponsive with shallow breathing, and no reassessment of oxygen saturation was documented after oxygen via simple mask was applied. Other licensed staff also failed to initiate BLS measures. LVN 1 reported that when called to the room, the resident was on oxygen via nasal cannula, breathing abnormally with two to three long breaths, and he recognized that 911 needed to be called, but he did not start CPR. LVN 2 stated that the resident was unresponsive and breathing slowly and acknowledged not being aware that ventilation could be provided when a resident is unresponsive and breathing slowly; vital signs she attempted to obtain were not documented. CNA 1 reported that no CPR was initiated by facility staff before EMS arrival. According to the EMS report and the responding Paramedic Captain, paramedics arrived to find the resident supine in bed, unresponsive, pulseless, apneic, and in asystole, with no CPR in progress and no measurable blood pressure, pulse, respirations, or oxygen saturation. The deficiency also included failure to ensure that emergency equipment and oxygen delivery systems were adequate and properly set up for resuscitation. The crash cart contained an oxygen regulator with a maximum output of only 8 L/min, which was insufficient to keep the BVM reservoir bag fully inflated and deliver 100% oxygen as required during resuscitation. The Paramedic Captain reported that the oxygen regulator connected to the resident’s oxygen tank was limited to 8 L/min, and another regulator found in the crash cart was also limited to 8 L/min, necessitating use of EMS’s own regulator to achieve 15 L/min, which delayed delivery of 100% oxygen. The Paramedic Captain also requested a backboard and was informed by RN 1 that the facility did not have one. Additionally, during surveyor observation and interview, RN 1 was unable to determine that the crash cart oxygen tank was empty and could not demonstrate proper connection of the suction tubing to the suction machine, stating he did not know how to determine whether the oxygen tank was empty or how to connect the suction machine. These failures occurred despite facility policies requiring immediate initiation of CPR for unresponsive residents without a DNR and the use of appropriate oxygen administration and emergency procedures. As a result of these findings, surveyors determined that the facility did not initiate immediate CPR for a full-code resident found unresponsive and did not perform continuous, uninterrupted CPR until EMS assumed care. The facility also failed to position the resident flat on a firm surface with airway opened, and failed to ensure availability and proper use of equipment capable of delivering 15 L/min oxygen for BVM use during resuscitation. EMS documentation indicated that no CPR was being performed upon their arrival, and the resident was found in cardiac arrest. The California Department of Public Health determined that the noncompliance constituted Immediate Jeopardy related to failure to ensure CPR was immediately performed on the resident.
Removal Plan
- RN 1 resigned from the facility.
- Staff involved (LVN 1, LVN 2) were removed by the DON from direct patient care until competency was validated.
- Immediate re-education was reinforced by the DON for direct care staff on immediate initiation of CPR, proper positioning on a firm/flat surface, continuous/uninterrupted CPR, crash cart utilization (including oxygen regulators capable of 15 L/min and backboards), and use of oxygen tanks (including how to determine if full or empty).
- Crash cart was checked by the DON and oxygen regulators were replaced to ensure 15 L/min capability; BVM bag and oxygen delivery systems were verified functional; oxygen tanks were ensured full.
- DON and DSD reviewed current certifications of all direct care staff and ensured only staff with validated CPR certification are assigned to residents' care.
- MRD identified residents designated as full code and ensured staff are aware where to find code status in paper medical records and the health record system.
- DON initiated in-service to licensed nurses (RNs/LVNs) and CNAs on the facility CPR emergency procedure policy with emphasis on calling code blue, locating code status, placing resident on firm/flat surface using backboard, head-tilt/chin-lift with oxygen via simple mask, using an oxygen regulator capable of 15 L/min for BVM, and performing continuous/uninterrupted CPR until EMS assumes care.
- Code Blue drills were initiated and will continue for skills check validation via return demonstration of licensed nurses and CNAs.
- A crash cart checklist was developed and implemented; crash cart and oxygen equipment checklist will be checked every shift by the lead licensed staff.
- Room changes will include updating residents' medical records to reflect new room assignment in both the electronic health record and physical medical record.
- A certified CPR instructor provided mandatory re-education and training for all licensed nurses and CNAs with return demonstration conducted.
- DSD/designee will validate that newly hired licensed nurses and CNAs have current valid CPR certification prior to scheduling for direct resident care; no direct care staff will work directly with residents without valid CPR certification.
- DON conducted a 1:1 in-service with LVN 1 and LVN 2 regarding medical emergency response (immediate CPR, proper positioning, continuous/uninterrupted CPR, crash cart utilization including 15 L/min regulators and backboards, and oxygen tank use/verification).
- DSD updated CPR certification status for all current direct care staff and will update monthly; DSD will audit and communicate with staff if CPR certification expires.
- DON/designee will provide a summary of findings for the monthly Quality Assurance Committee (QAC).
Failure to Ensure Competent Nursing Response During Resident Respiratory/Cardiac Emergency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nursing staff possessed and demonstrated the competencies required to provide emergency care consistent with facility policies and resident assessments. A resident with a POLST indicating full code and full treatment status was admitted for long-term care with diagnoses including diabetes mellitus, congestive heart failure, dementia, and atrial fibrillation. The resident’s MDS showed severe cognitive impairment and dependence on staff for all ADLs, and the care plan identified potential for cardiac distress related to cardiac conditions, directing staff to monitor for symptoms such as dyspnea, shortness of breath, tachycardia, and to promptly notify the physician if symptoms occurred. Physician orders also included PRN oxygen 2–5 L via nasal cannula for shortness of breath or oxygen saturation below 92%. Surveyors found that nursing staff lacked critical emergency response skills and did not follow the facility’s CPR and oxygen administration policies when the resident became unresponsive with difficulty breathing. RN 1 was observed to be unable to determine that the oxygen tank on the crash cart was empty and could not demonstrate how to connect the suction tubing to the suction machine, and later stated not knowing how to check if the oxygen tank was empty or how to connect the suction machine. RN 1 also could not verbalize that a backboard was needed during CPR. Review of RN 1’s competency records showed no skills and competency evaluation for use of a suction machine, vital signs, or emergency response. The DON reported that RN 1 had a language barrier and that she paired RN 1 with experienced LVNs due to RN 1’s comprehension and communication needs. During the resident’s decline, LVN 2 reported that the resident had been stable earlier and had eaten 100% of dinner, but later was weak and breathing slowly. LVN 2 attempted to take vital signs but was unable to document the results and stated that paramedics initiated CPR upon arrival. The Paramedic Captain reported that, on arrival, facility staff were not performing CPR, a backboard was not in place, and the oxygen valve regulator connected to the oxygen tank delivered only up to 8 L/min. LVN 2 stated she was not aware that ventilation could be provided when a resident was unresponsive and breathing slowly and acknowledged inaccuracies in documentation times. Facility policies required assessment of symptoms such as shallow breathing and vital signs during oxygen therapy, immediate initiation of CPR by licensed staff certified in CPR when an individual is unresponsive and not breathing normally (unless a DNR is present), and accurate, time-specific documentation of procedures and treatments. The facility’s staffing policy required sufficient numbers of nursing staff with appropriate skills and competency, which was not met for the involved licensed nurses.
Failure to Assess and Monitor Psychiatric Resident Leads to Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to assess, monitor, supervise, and provide necessary care for a newly admitted resident with significant psychiatric and behavioral issues, which resulted in that resident striking another resident. Prior to admission, a General Acute Care Hospital (GACH) psychiatric evaluation documented that the resident had a history of depression, anxiety, frustration, irritability, agitation, lack of motivation, dark thoughts, suicidal ideation with a plan to overdose, difficulty resisting urges to self-harm, unpredictability, impaired coping skills, and impaired insight, judgment, and impulse control. The GACH history and physical further indicated the resident had been admitted for increased agitation and anxiety. Upon admission to the facility, the resident’s diagnoses included paranoid schizophrenia, anxiety, and major depressive disorder. Despite this extensive psychiatric history, the facility’s social services and nursing staff did not adequately review or incorporate the hospital records into the resident’s initial assessments or care planning. The Social Service History and Initial Assessment completed the day after admission left multiple psychosocial adjustment factors blank, including distressed mood, history of depression, history of suicidal ideation/gestures, anxiety, insomnia, use of psychotropic medications, history of drug/alcohol abuse, disruptive behavior, difficulty controlling behavior, agitation/aggression, and resistance to care. The Social Service Director later acknowledged she had not reviewed the hospital records before completing the assessment and was unaware of the resident’s documented dark thoughts, suicidal ideation, and increased agitation. The Interdisciplinary Team (IDT) meeting held the same day did not document or discuss the resident’s past behaviors from the GACH records, even though the IDT noted the resident would be admitted to psych services and monitored daily. Nursing staff also failed to fully assess and plan for the resident’s behavioral risks upon admission. The admitting nurse reported receiving information from the GACH that the resident had increased aggressive behavior but did not ask for specifics, did not review the hospital records that accompanied the resident, and only initiated monitoring orders for anxiety, schizophrenia, and insomnia based on limited observations of repetitive anxious questions. Another nurse confirmed that the baseline care plan completed on admission noted psychotropic medication use but left mental health needs and behavioral concerns blank, and that there was no behavior management care plan in place before the incident. Psychiatric and psychological consults were not ordered until days after admission, and the resident had not been evaluated by a psychiatrist in the facility before the event. On the morning of the incident, multiple staff members observed the resident walking up and down the hallway while waiting for a smoke break. Payroll staff and central supply staff both witnessed the resident suddenly stop behind another resident seated in a wheelchair and strike that resident on the upper back with an open hand, describing the contact as a hard smack with an audible sound. A CNA confirmed that the resident had rushed through breakfast and was pacing the hallway before the smoke break when the incident occurred. Following the event, a change of condition evaluation documented that the resident had allegedly physically abused another resident by slapping them and that the resident stated he did not know why he did it. The facility’s own policies required thorough evaluation of behavioral symptoms, identification of underlying causes, assessment of severity and safety risk, and immediate implementation of safety strategies, as well as completion of a baseline care plan within 48 hours of admission to meet immediate needs; however, these processes were not effectively carried out for this resident prior to the incident.
Failure to Develop Comprehensive Care Plan for Visually Impaired Resident
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan addressing the needs of a legally blind resident. The resident’s admission record showed diagnoses including bilateral blindness, respiratory failure, and diabetes, and the history and physical documented that the resident had capacity to understand and make decisions. The MDS indicated the resident was cognitively intact and required moderate assistance with oral hygiene, toileting hygiene, dressing, and footwear. During interview, the resident reported being unable to visually identify meals and stated she used her hands to determine what she was eating by feeling the texture and temperature of the food. A nurse confirmed the resident was blind in both eyes and stated that assistance was usually provided for meal set-up, including identifying food items and their location on the tray, as well as for transfers and toileting due to the visual impairment. Record review with nursing staff revealed there was no care plan initiated to address the resident’s specific diagnosis of blindness. RN 2 acknowledged that a care plan should have been initiated and should have included measurable goals and interventions to address the resident’s behaviors and needs, including measures to decrease stress and anxiety. The MDS nurse also confirmed there was no care plan in place for the resident’s blindness. This was inconsistent with the facility’s written policy on comprehensive, person-centered care plans, which requires development and implementation of a care plan with measurable objectives and timetables for each resident, including after significant changes in status, and ongoing revision as resident conditions change.
Failure to Follow Oxygen and Respiratory Therapy Infection Control Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its infection prevention and control program related to oxygen and respiratory therapy equipment for one resident. The resident was admitted with chronic respiratory failure, obstructive pulmonary disease, and a delusional disorder, and was cognitively intact with moderate assistance needs for ADLs. The resident had a physician’s order for continuous oxygen at 5 L/min via nasal cannula. During observation in the resident’s room, surveyors noted that the oxygen tubing in use was not labeled with a date or time to indicate when it was last changed, and the nebulizer tubing attached to the resident’s breathing treatment device was labeled with a date showing it had last been changed on 1/5/2026. In interviews conducted at the time of observation, an LVN stated that oxygen tubing must be dated so staff know when to change it, and an RN confirmed that the oxygen tubing was not labeled and should be labeled weekly to ensure it is changed to prevent infection. The RN also stated that the nebulizer tubing, dated 1/5/2026, should have been changed every seven days and therefore should have been changed by 1/19/2026. The RN further stated there was no way to know when the oxygen tubing was last changed due to the lack of labeling or documentation. Review of the facility’s policies showed that the Oxygen Administration policy required documentation of the date and time oxygen set-up was performed in the medical record, and the Respiratory Therapy policy required changing oxygen cannula and tubing every seven days and documenting the date and time respiratory therapy was performed. These policy requirements were not followed for this resident’s oxygen and nebulizer equipment.
Failure to Timely Respond to Call Lights and Provide ADL/Incontinence Assistance
Penalty
Summary
The deficiency involves the facility’s failure to respond to resident call lights in a timely manner and to provide needed assistance with activities of daily living (ADLs), specifically toileting and incontinence care, for three residents. Facility policy on the call system required that calls for assistance be answered as soon as possible and no later than five minutes, and the ADL policy required appropriate support and assistance with hygiene and elimination in accordance with the care plan. Interviews with staff, including the Director of Staff Development (DSD), Licensed Vocational Nurse (LVN) 1, and the Administrator, confirmed that call lights are to be within residents’ reach and answered promptly, with the DSD specifying no more than 15 minutes and stating that a resident should not wait one hour for assistance. Resident 1 was admitted with encephalopathy, epilepsy, and hypertension, was bedbound, had decreased tone and no movement on the right side, and had severely impaired cognitive skills. The MDS showed he required substantial assistance with toileting hygiene, showering, dressing, and transfers, and was always incontinent of urine and bowel. His care plan required monitoring and assisting with ADLs, keeping him clean and dry, changing adult briefs as needed, and ensuring the call light was within reach and answered promptly. Family Member 1 reported that on one occasion Resident 1 waited over an hour for his adult brief to be changed and that call bells were frequently sounding when she visited. During an interview, Resident 1 stated he used the call light to request assistance for brief changes and that it took about one hour for staff to respond, leaving him in wet and soiled briefs, which he described as uncomfortable. Resident 2 was admitted with benign prostatic hyperplasia, polyneuropathy, lumbar spondylosis, and bilateral knee osteoarthritis. His MDS indicated moderately impaired cognition, a need for supervision with toileting hygiene and other ADLs, and frequent urinary and bowel incontinence. His care plan documented an ADL deficit related to his osteoarthritis and polyneuropathy, with goals that his ADL needs be met daily and interventions to monitor and assist with ADLs, keep him clean and dry, change him as needed, and keep the call light within reach with prompt staff response. During observation and interview, Resident 2 was seated in a wheelchair next to his bed while the call light was on top of the bed, out of his immediate reach. He reported that he used a urinal for urination and an adult brief for bowel movements and that after pressing the call light for a brief change, he often had to wait one to two hours for staff to respond. Resident 3 was admitted and later readmitted with hemiplegia and hemiparesis following a stroke, osteoarthritis of both shoulders, and glaucoma. His history and physical indicated he had decision-making capacity, and his MDS showed intact cognition but a need for substantial assistance with toileting hygiene, repositioning, and transfers, with frequent urinary incontinence and occasional bowel incontinence. He was on a bowel toileting program. His care plans documented bowel and bladder interventions, including assistance with toileting as needed, keeping the call light within reach for assistance, and providing limited to extensive assistance by one staff member for personal hygiene and toileting, including an extensive-assistance toileting schedule. During observation, Resident 3 was in his wheelchair in front of his bed with the call light placed on top of the bed, not within his reach. He stated he used the call light to request help going to the bathroom and used the bathroom call light to request cleaning after bowel movements, which he described as very messy, and reported that he typically waited at least one hour before someone came to his room. Staff interviews confirmed that call lights are intended as the primary means for residents to request assistance with needs such as brief changes and toileting, and that they are expected to be within reach and answered timely, which did not occur for these residents. As a result of this deficient practice, the residents were placed at risk for infection, skin breakdown and discomfort.
Failure to Provide Ordered Oral Pain Medication and Adequate Pain Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain management for a resident with a toothache and facial swelling. The resident was admitted with encephalopathy, epilepsy, and hypertension, was bedbound with decreased tone and no movement on the right side, and had severely impaired cognitive skills per the MDS. The MDS also showed the resident required substantial assistance with ADLs and that the staff assessment for pain was left blank, with no pain management regimen documented and the resident denying pain at that time. The care plan, revised in November, identified dental health problems related to poor oral hygiene and missing teeth, with interventions to monitor, document, and report signs and symptoms of oral or dental pain. On 12/27/2025, a change of condition evaluation documented mild swelling of the lymph nodes and left cheek, and a pain level of 5/10 in the upper left jaw. A physician order dated 12/27/2025 directed that the resident receive Orajel 2X Toothache & Gum Mouth/Throat Gel 20-0.26%, one application by mouth every six hours as needed for toothache for seven days. There was also an existing PRN order for acetaminophen 325 mg, two tablets by mouth every four hours as needed for moderate pain (pain scale 4–7), and an order to monitor the resident’s pain level every shift using a pain scale. However, review of the December MAR showed no documented evidence that the resident received either acetaminophen or Orajel from 12/27/2025 to 12/29/2025, and the MAR entries for those dates indicated the resident denied pain. Family members reported that during the three days after the Orajel was ordered, they frequently informed nursing staff that the resident was having mouth pain and discomfort, and were repeatedly told the medication had not yet arrived from the pharmacy. One family member stated the Orajel was not delivered until 12/30/2025 and that nothing was done until that day, despite offering to pick up the medication. The resident later reported experiencing frequent pain at 8/10 severity in the upper left jaw during that period and difficulty eating, having to chew on the right side and eat slowly. The Director of Staff Development confirmed that the Orajel was ordered on 12/27/2025 but first administered on 12/30/2025, and that there was no documented evidence of Orajel or Tylenol administration or of a thorough pain assessment, including pain level, location, frequency, and description, from 12/27/2025 to 12/29/2025. The facility’s pain protocol required assessment at onset of new pain or worsening pain, identification of pain characteristics, and regular reassessment, which were not documented as having been carried out during this time. The deficiency is that the facility failed to provide the ordered Orajel for three days after the physician’s order for toothache pain and failed to document and perform thorough pain assessments despite reports of pain and an existing pain monitoring order. As a result, the resident reported consistent pain at 8/10 and difficulty eating during that period, which the report states could lead to weight loss and/or prevent participation in ADLs, affecting quality of life.
Failure to Provide Appropriate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with open wounds on the right and left temporal areas. Despite physician orders and care plan interventions requiring pain assessment and management before, during, and after wound treatments, there was no documented evidence that pain levels were monitored or that pain medications were offered or administered prior to wound care on multiple occasions. Treatment Administration Records (TARs) and Medication Administration Records (MARs) were frequently left blank for required pain assessments, and staff interviews confirmed that pain management protocols were not consistently followed. The resident was observed to exhibit both verbal and non-verbal signs of pain during activities of daily living and wound care, including screaming, guarding, and refusing care due to pain. The resident had a history of squamous cell carcinoma with open wounds on the face, which were described as tender, bleeding, and interfering with daily activities. The care plan identified both acute and chronic pain, with interventions to monitor pain characteristics and non-verbal indicators every shift and as needed. Orders were in place for both non-pharmacological and pharmacological pain management, including acetaminophen and hydrocodone-acetaminophen as needed for moderate to severe pain. However, documentation and staff interviews revealed that these interventions were not consistently implemented, and the resident was not always premedicated prior to painful treatments. Additionally, the facility failed to reevaluate the resident's pain management plan and notify the attending physician when the resident refused wound care due to pain, as required by facility policy. There was no evidence that probable causes of pain episodes were monitored or documented, nor that non-verbal pain indicators were consistently assessed. Staff, including nurses and CNAs, reported the resident's sensitivity and pain during care, but these observations were not systematically recorded or communicated to the physician. The lack of proper pain assessment and management resulted in the resident experiencing unnecessary pain and negatively impacted the resident's quality of life.
Breakdown in Physician Communication and Collaboration for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to ensure continuous communication and collaboration among multiple physicians involved in the care of a resident with complex medical needs, including squamous cell carcinoma, open wounds, and dementia. The resident was under the care of an Attending Physician, a Wound Care Specialist, a Dermatologist, and an Oncologist at various times, but there was a breakdown in communication regarding who was responsible for the resident's overall medical management. Documentation and interviews revealed that the Wound Care Specialist discontinued involvement after learning the Dermatologist was managing the case, but this change was not clearly communicated to nursing staff or reflected in the resident's care orders. As a result, nursing staff assumed the Wound Care Specialist was still overseeing wound care, while the Attending Physician and DON believed the Oncologist was managing the resident's cancer and related wounds. The resident's medical records showed inconsistencies in wound documentation, pain assessments, and care planning. The Minimum Data Set (MDS) assessments did not consistently indicate the presence of open lesions or pain, despite clinical observations and physician notes describing significant wounds and cancerous lesions. Orders for wound care consults were present in the record, but there were gaps in actual wound care visits and unclear documentation regarding the discontinuation of wound care services. The lack of clear direction and coordination among the physicians led to confusion among nursing staff about who was responsible for wound care and pain management. Interviews with facility staff, including nurses and the DON, confirmed that there was a lack of awareness about changes in physician responsibility and ongoing confusion about the resident's care plan. The facility's Bioethics Committee was identified as the responsible party for the resident's care due to the absence of family, but this committee did not ensure effective communication and collaboration among the physicians. The facility's policy required the attending physician to participate in assessment and care planning, but this was not effectively implemented, resulting in a breakdown of communication and collaboration for the resident's overall medical management.
Failure to Report, Investigate, and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse prevention, reporting, and investigation policies following a physical altercation between two residents. On the morning of the incident, staff heard a commotion and discovered that one resident had sustained a visible mark on the forehead, allegedly caused by another resident. Staff members separated the residents and reported the incident to the Administrator, who instructed them not to report the event further. No documentation of the incident was made in either resident's clinical records, and no notifications were sent to responsible parties or physicians. Despite the facility's policies requiring immediate reporting and investigation of abuse allegations, the incident was not reported to the Department of Public Health, local law enforcement, the Ombudsman, or Adult Protective Services. The Administrator, who was also the designated Abuse Prevention Coordinator, did not initiate or document an investigation, nor did he interview involved staff or witnesses. Staff members did not complete required forms or document the injury and failed to develop or update care plans for either resident involved in the altercation. Both residents had significant cognitive impairments and behavioral symptoms documented in their medical histories, with one resident unable to make decisions and the other requiring moderate assistance with mobility. The lack of documentation, reporting, and care planning following the incident meant that the facility did not take steps to protect the residents from further harm or address the underlying behavioral issues. The facility's failure to follow its own policies placed the residents and others at risk for further abuse and neglect.
Failure to Timely Report Resident-to-Resident Altercation and Injury
Penalty
Summary
The facility failed to report an alleged resident-to-resident altercation within the required 24-hour timeframe to the California Department of Public Health (CDPH), as mandated by its own Abuse Reporting and Investigation Policy and Procedure. Two residents, both with severe cognitive impairments and significant behavioral and communication challenges, were involved in an incident where one resident sustained a visible red mark on the forehead. Despite the presence of physical evidence and staff awareness of the altercation, there was no documentation of the incident in either resident's clinical records, nor was there evidence of notification to responsible parties or physicians. Multiple staff members, including a staff coordinator and two licensed nurses, witnessed or were informed of the incident and observed the injury. The staff coordinator documented the injury with a photograph, and both nurses confirmed that the administrator was notified of the event. However, the administrator instructed staff that he would handle the situation and directed them not to report the incident further. As a result, the incident was not reported to law enforcement, the Ombudsman, or CDPH as required by facility policy and state regulations. Interviews with staff and review of facility records revealed that no Change in Condition Evaluations were completed for either resident following the altercation, and no follow-up investigation or interviews were conducted. The administrator later acknowledged the lack of documentation and reporting, and could not provide an explanation for the failure to follow required procedures. The facility's policy clearly states that all allegations of abuse, including injuries of unknown source, must be reported to appropriate agencies within specified timeframes, which was not done in this case.
Failure to Implement and Document Weekly Wound Assessments for Pressure Injuries
Penalty
Summary
A resident with a history of metabolic encephalopathy, hemiplegia, hemiparesis, and diabetes mellitus was admitted with a Stage 3 pressure injury on the sacrum and suspected deep tissue pressure injuries (SDTPI) on both heels. The care plan for these wounds required weekly assessments and documentation by the wound doctor (WMD) and treatment nurse (TN), including measurements of each wound and reporting of any changes to the medical doctor. The resident was identified as bedfast with limited mobility and a moderate risk for pressure sores, requiring significant assistance with daily activities. Despite these documented needs and care plan interventions, there was no evidence in the facility's records of weekly wound assessments or documentation by either the WMD or TN for the resident's pressure injuries. The TN admitted to forgetting to inform the WMD, resulting in missed weekly assessments on two occasions. The Director of Nursing (DON) confirmed that there was no documentation of initial or weekly wound assessments as required by the care plan. Facility policies required regular risk assessments, ongoing evaluation of skin conditions, and documentation of interventions and their effectiveness. However, these protocols were not followed, as the resident did not receive the required weekly wound evaluations and documentation, nor were the wounds reported to the WMD for evaluation and management as outlined in the care plan.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team failed to evaluate and assess a resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate. The resident, who had diagnoses including delusional disorder, diabetes, severe visual impairment, and anemia, was observed with five bottles of vitamin supplements at her bedside. The resident stated she had been taking the vitamins herself for years and was aware of their presence at her bedside. During interviews, staff members, including an LVN and the DON, confirmed there was no assessment or evaluation by the IDT or physician to determine if the resident was appropriate to self-administer supplements, nor was there a physician's order for self-administration. Record review showed that the resident required varying levels of assistance with activities of daily living and had episodes of incontinence. The facility's policy required an IDT assessment and documentation for residents to self-administer medications, as well as ongoing review by nursing staff. However, there was no documentation of any assessment or evaluation for this resident regarding self-administration of medications, and nursing staff were unaware of the supplements at the bedside. The facility's failure to follow its own policy and procedures resulted in the resident self-administering supplements without proper evaluation or oversight.
Failure to Complete Timely Comprehensive Assessment and Care Plan
Penalty
Summary
The facility failed to complete a comprehensive assessment of a resident's needs, strengths, goals, and preferences within the required 14-day timeframe after admission, as mandated by both facility policy and federal regulations. The Minimum Data Set (MDS) for the resident, who was admitted with diagnoses including delusional disorders and severe bilateral visual impairment (category 3 blindness), was due by 8/21/2025 but was not completed until 8/25/2025, four days late. The incomplete and delayed assessment resulted in the absence of a care plan addressing the resident's significant visual impairment. During the period before the assessment was completed, the resident expressed frustration with her care, stating that staff did not know how to address her needs. Staff interviews revealed uncertainty in managing the resident's care, particularly regarding her refusal of incontinence care, and the DON acknowledged that the lack of a timely and thorough assessment contributed to the failure to address all of the resident's needs. Review of facility policies confirmed the requirement for timely MDS completion and comprehensive assessment to inform care planning.
Failure to Complete Weekly Skin Assessments for Resident with MASD
Penalty
Summary
A resident was admitted to the facility with Moisture-Associated Skin Damage (MASD) to the buttocks extending to the groin area, along with diagnoses of diabetes and anemia. The resident was identified as being at high risk for pressure injury, required partial to moderate assistance with toileting and personal hygiene, and was frequently incontinent of urine with occasional bowel incontinence. The care plan for the resident included monitoring and documenting the location, size, and treatment of the skin injury, as well as reporting abnormalities, failure to heal, and signs of infection to the physician. Facility policy required weekly skin assessments for residents at risk of pressure injuries. Despite these requirements, the resident did not receive a weekly skin assessment for the MASD from admission through the review period. Both the Director of Nursing (DON) and the Treatment Nurse (TN) confirmed that the weekly assessment was missed, and the electronic health record showed no documentation of such assessments. The facility's policy and procedure on prevention of pressure injuries specifically called for weekly risk assessments and ongoing evaluation of interventions, which was not followed in this case.
Failure to Provide Adequate Behavioral Health Interventions and Supervision
Penalty
Summary
A resident with diagnoses of major depressive disorder, anxiety, and schizophrenia was readmitted to the facility following a recent hospital stay. Upon readmission, the resident exhibited escalating behavioral symptoms, including agitation, repeated requests to go to the hospital, verbalization of pain and chest pain, and multiple incidents of moving herself to the floor. Despite these behaviors, staff did not implement a 1:1 sitter intervention, did not adequately monitor or supervise the resident, and failed to document or assess the resident's complaints and behaviors as required by facility policy. Throughout the evening and night, the resident's behavior continued to escalate, with repeated reports from CNAs to LVNs about the resident's agitation, yelling, and requests for hospital transfer. The LVNs did not follow up with the physician for new orders after initial communication, nor did they notify the physician of the resident's ongoing pain complaints, chest pain, or behavioral escalation. There was no evidence of additional interventions or individualized care planning to address the resident's mental health needs or to ensure safety, despite clear indications that the resident's behavior was not being managed and posed a risk to herself and others. The situation culminated in the resident breaking a window, obtaining a large shard of glass, and brandishing it toward her neck while demanding to be sent to the hospital. Emergency services were called, and the resident was transferred to an acute care hospital for a suicide attempt. Interviews and record reviews confirmed that staff did not follow facility policies on behavioral assessment, intervention, monitoring, or change in condition, and failed to provide the necessary treatment and services to attain the highest practicable mental and psychosocial well-being for the resident.
Failure to Prevent Resident-to-Resident Abuse and Ensure Supervision
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and verbal abuse by not adequately separating and supervising two residents after a physical altercation. One resident, who had a history of schizoaffective disorder, cognitive impairment, and lacked decision-making capacity, struck another resident during a disagreement about a curtain. Staff responded by separating the residents and moving the aggressor to another room, but did not ensure continuous supervision. Despite being moved, the aggressor was able to return to the original room, where further verbal threats were made toward the other resident. Staff interviews revealed lapses in communication and supervision, as well as a lack of immediate follow-up documentation regarding the second incident. The aggressor was not properly monitored, allowing for a second encounter that resulted in additional verbal abuse and threats. The resident who was the victim of the altercation reported feeling unsafe due to the repeated access of the aggressor to the shared room. Staff acknowledged that the residents should have been completely separated and that the second incident was not properly documented or communicated to the physician. The facility's policy prohibits all forms of abuse, but the actions taken were insufficient to prevent further abuse and ensure resident safety.
Failure to Provide Bed Hold Policy Notification Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written information regarding bed hold policies to a resident and their responsible party upon the resident's transfer to a General Acute Care Hospital (GACH). The resident, who had diagnoses including Type 2 Diabetes, COPD, and schizoaffective disorder, was transferred for psychiatric evaluation due to medication refusal, hostile behavior, and increased delusions. Documentation showed a physician's order for a seven-day bed hold, but there was no evidence that the resident or their responsible party received written notification about the bed hold policy at the time of transfer or within 24 hours, as required by facility policy. Interviews with the resident, the responsible party, and facility staff confirmed that neither the resident nor the responsible party was informed or provided with written information about the bed hold policy during or after the transfer. The Director of Nursing acknowledged that the facility's policy requires written notification upon admission and at the time of transfer, or within 24 hours in the case of an emergency, but there was no documentation that this occurred. The facility's policy and procedure for bed holds and returns, revised in 2022, was not followed in this instance.
Failure to Develop Comprehensive Care Plan for Behavioral Health Needs
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan to address a resident's behaviors related to bipolar disorder and depression. Despite the resident having documented diagnoses of hemiplegia, seizures, mood disorder, and depression, and being prescribed medications such as Lexapro and Risperidone for these conditions, the care plans did not include specific interventions or monitoring related to these behavioral health needs. The resident's Minimum Data Set and psychiatric examination confirmed the presence of depression and mood disorder, yet these were not reflected in the active care plans. During interviews and record reviews, the DON acknowledged that the care plans lacked specific focus on the resident's depression, bipolar disorder, and the use of related medications. The facility's own policy and procedure required care plans to incorporate all problem areas identified through comprehensive assessment and to be revised as the resident's condition changed. The absence of these care plan elements meant that the facility could not effectively track or manage the resident's behavioral health conditions.
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its policy and procedure for abuse prevention and reporting following a verbal altercation between a resident and an LVN. The incident occurred on 2/11/2025, when the resident had a verbal argument with the LVN, which was not investigated by the facility. The facility did not suspend the LVN pending the investigation, as required by their policy, nor did they prevent further contact between the LVN and the resident. The resident involved in the incident was admitted with diagnoses including lack of coordination, muscle wasting, and depression. The resident had intact cognition and required moderate assistance for self-care and mobility. On the day of the incident, the resident called the police to report the altercation, but there was no documented evidence that the facility staff interviewed the resident or investigated the allegation of abuse. Additionally, the resident's roommate, who witnessed the argument, was not interviewed by the facility staff. Interviews with facility staff revealed that the incident was not reported to the DON or ADM, and the LVN continued to have contact with the resident after the altercation. The facility's policies require that all allegations of abuse be reported and investigated, and that any employee accused of abuse be placed on leave with no resident contact until the investigation is complete. The failure to follow these procedures placed the resident and other residents at risk for potential abuse.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to notify the State Survey Agency (SA) within the required two-hour timeframe following an allegation of verbal abuse made by a resident against a Licensed Vocational Nurse (LVN). The incident occurred when the resident called the police, who arrived at the facility to investigate the complaint. Despite the police visit and the resident's allegation, the facility staff, including the Registered Nurse (RN) and the LVN involved, did not report the incident to the facility's Abuse Coordinator or the SA as mandated by the facility's policy. The resident involved in the incident was admitted with diagnoses including lack of coordination, muscle wasting, and depression, and was assessed to have intact cognition and the capacity to make decisions. The resident's behavioral symptoms care plan noted a history of yelling, screaming, and cursing, but did not include taking the resident to the patio as an intervention. The incident involved a verbal altercation between the resident and the LVN, during which the resident accused the LVN of making threatening remarks. Despite the seriousness of the allegation, the staff failed to document interviews with the resident or report the incident to the appropriate authorities. Interviews with facility staff revealed a lack of communication and adherence to reporting protocols. The Director of Nursing (DON) and the Administrator (ADM) were not informed of the police visit or the resident's allegations. The facility's policy requires immediate reporting of abuse allegations, defined as within two hours, to the administrator and relevant authorities. However, the staff, including the RN, LVN, and Certified Nursing Assistant (CNA), did not fulfill their mandated reporting duties, resulting in a failure to address the resident's complaints and protect them from potential further abuse.
Failure to Implement Smoking Policy and Supervision
Penalty
Summary
The facility failed to implement its smoking policy and procedure, leading to an environment with significant accident hazards for eight residents who were smokers. These residents, identified as unsafe smokers, were not provided with the necessary supervision while smoking. Additionally, one resident's smoking assessment was not completed, and another resident was found storing cigarettes and lighters in their drawer, contrary to the facility's policy. The facility did not ensure that residents who were assessed as unable to light tobacco safely did not share cigarettes or use lighters unsupervised. There were instances where a receptionist provided lit cigarettes to residents, allowing them to smoke unsupervised during nonscheduled smoking times. Furthermore, several residents were not identified as noncompliant with the smoking policy despite smoking during nonscheduled times, and they were allowed to keep smoking materials in their possession. The facility lacked a designated staff member to supervise the smoking patio area during both scheduled and nonscheduled smoking times. This lack of supervision and failure to secure smoking materials posed a risk of accidental burns and fire hazards, potentially affecting the health and safety of residents, staff, and visitors. The California Department of Public Health identified an Immediate Jeopardy situation due to these deficiencies.
Removal Plan
- Residents 3, 56 and 67's two packs of cigarettes and lighter were taken from Residents 3, 56 and 67's bedside drawers by the DON and kept in the locked drawer in the receptionist desk.
- Resident 67 was provided education by the Social Service Director (SSD), and the DON regarding facility staff keeping the smoking materials and Resident 67 would not smoke without any supervision by the facility staff. Resident 67 agreed to comply with the facility staff after discussion with Resident 67. The facility's receptionist would be the keeper of the smoking items and smoking materials. Only staff would have access to the keys of the smoking items.
- Resident 3 was educated by the SSD on the facility's smoking P&P including surrendering cigarettes and smoking materials to facility staff.
- Residents 3 and 56's Care Plans (CPs) for smoking were updated by the licensed nurses indicating the interventions for Resident 3 and 56 to safety smoke, and the DON initiated additional CPs for Resident 3 and 56's non-compliance with smoking per P&P.
- Resident 136 was transferred to the General Acute Hospital (GACH) and would be re-educated by the SSD or designee regarding the facility's smoking P&P including not giving and not receiving cigarettes from other residents.
- The smoking attendants were provided education by the DON/Designee on the facility's smoking P&P regarding the importance of supervision and being on the designated smoking area during smoking schedule. No smoking attendant would be assigned as a smoking attendant without being educated on the importance of being at smoking area during smoking schedule.
- The facility implemented dedicated smoking attendants to monitor smokers 24 hours a day during scheduled and nonscheduled smoking times. The Activities Director (AD)/designee was responsible to schedule the smoking attendants weekly or as needed. The dedicated smoking attendant would log the behavior of the identified non-compliant residents and would intervene accordingly if residents found to not following the facility's P&P such as smoking on nonscheduled times or having in possession smoking paraphernalia when inside or outside the facility.
- Residents 2, 9, 14, and 18's CPs were updated to reflect smoking non-compliance.
- Resident 9 was re-educated regarding the facility's P&P for smoking including lighting cigarettes in the smoking area by the delegated smoking supervisor.
- Residents 3 and 56 were provided education by the SSD about safety on smoking and not to smoke without any supervision by staff.
- Resident 14 was re-educated by the SSD regarding the facility's smoking P&P including not giving and not receiving cigarettes from other residents.
- REC 1 was provided a 1:1 in-service by the DON regarding the facility's new smoking P&P including supervision of smokers.
- The SSD and Interdisciplinary Team (IDT) members initiated a discussion with all residents who smoke (not limited to Residents 3 and 56) regarding the facility's P&P on smoking and importance of adhering to the policy for safety. Residents 3 and 56 agreed on complying per IDT discussion.
- The quality Assessment and Assurance Committee (QAA) members with the medical director and administrator updated the smoking policy with the policy not limited to addressing supervision of smokers and indicating potential outcomes for the non-compliant smokers.
- The DSD/designee initiated an in-service to licensed, non-licensed staff and smoking attendants on the importance of ensuring supervision of smokers In-service to all staff would be continued until all smoking attendants that would be scheduled were provided education on supervision.
Deficiencies in POLST and Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) were included in the clinical records of three residents. Resident 66, who was admitted with anxiety disorder and dementia, had a POLST that was not in the paper chart but was instead kept in a hospice chart under the nurse's station desk. This practice could hinder quick access to the POLST during emergencies. Similarly, Resident 69's POLST was not in the paper chart but in a binder under the desk, awaiting a physician's signature since August 2024. The absence of the POLST in the resident's chart could lead to confusion about the resident's wishes during medical emergencies. Resident 77's POLST was also missing from the paper chart, and the staff was unaware of the resident's wishes for emergency medical treatment. The facility also failed to ensure that the POLST and Advance Directive (AD) acknowledgment forms were present in the clinical records of Resident 14. This resident, who had been diagnosed with bipolar disorder, schizoaffective disorder, and nicotine dependence, was under conservatorship due to being gravely disabled. Despite being cognitively intact according to a recent assessment, there was no documented evidence that a POLST or AD acknowledgment form was completed or offered to Resident 14. The absence of these documents in the clinical records could lead to uncertainty about the resident's healthcare preferences in emergencies. The facility's policies and procedures require that POLST forms be signed by both the resident and the physician and filed in the resident's clinical records. The Advance Directives policy mandates that residents be provided with information about their rights to formulate an advance directive and that staff document any assistance offered or decisions made by the resident. The failure to adhere to these policies resulted in the potential for conflict with the residents' healthcare decisions during emergencies.
Failure to Address Resident's Refusal of Podiatric Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who refused treatment for long nails with a fungal infection and podiatric care. The resident, who was admitted with diagnoses including paraplegia and primary osteoarthritis, had a physician order for podiatry care every 60-90 days. Despite having the capacity to understand and make decisions, the resident refused podiatric evaluation and treatment on a specified date, which was not addressed in the care plan. The facility's staff did not assess the reason for the resident's refusal or explain the risks and benefits of refusing treatment. There was no care plan or interdisciplinary team meeting conducted to address the refusal, as confirmed by the Social Service Director and the Director of Nurses. The facility's policy requires that if a resident refuses care, an appropriate member of the interdisciplinary team should meet with the resident to discuss concerns and document the refusal in the medical record, which was not done in this case.
Insufficient Staffing for Resident Supervision
Penalty
Summary
The facility failed to ensure sufficient staffing to monitor and supervise residents during both scheduled and nonscheduled smoking times, as well as to monitor residents at risk of elopement. On a specific day, observations revealed that several residents were smoking in the designated area without staff supervision. Interviews with staff members, including activity staff and a licensed vocational nurse, confirmed that due to short staffing, they were unable to adequately supervise the smoking area and monitor residents at risk of elopement simultaneously. This lack of supervision was attributed to the facility's ongoing staffing issues. The Director of Nurses acknowledged that each designated area for smoking and elopement should have been assigned to one activity staff member per area, but due to insufficient staffing, this was not possible. The facility's policy and procedure on staffing indicated that sufficient numbers of nursing staff with appropriate skills and competency should be provided to meet resident needs, but this was not adhered to, leading to the deficiency in supervision during smoking times and monitoring of residents at risk of elopement.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to properly store medications for four of five sampled residents, leading to potential issues with medication integrity and security. Insulin Glargine pens for Residents 3, 69, and 76 were not stored correctly, as they were found in a refrigerator with water dripping from the freezer compartment, potentially compromising the medication. Additionally, Lorazepam oral concentrate for Resident 66 was stored in a refrigerator that was not maintained at the required temperature range, which could affect the medication's efficacy. The facility also failed to maintain a sanitary environment for medication storage. During an observation, a mini refrigerator in the medication room was found with water pooling from a melting freezer compartment, affecting the storage of Insulin Glargine pens and Lorazepam oral concentrate. The Licensed Vocational Nurse (LVN) was unaware of the issue until informed by the surveyor, and the Maintenance Supervisor noted that the refrigerator's temperature setting was incorrect, leading to the melting ice. The Director of Nursing (DON) confirmed that the refrigerator's temperature was out of range, which could render the Lorazepam ineffective. Furthermore, the facility did not ensure that controlled medications were stored in separately locked, permanently affixed compartments. Resident 66's Lorazepam oral concentrate was found in an unlocked refrigerator, contrary to the facility's policy. This oversight could lead to undetected diversion or loss of controlled medication. The facility's policy, dated April 2019, requires all drugs and biologicals to be stored securely and under proper conditions, which was not adhered to in these instances.
Deficient Sanitation and Temperature Logging in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed under sanitary conditions, as evidenced by missing documentation in several critical logs. During an initial kitchen tour, it was observed that the sanitization sink solution was not consistently logged, with missing entries for several days in October. The Dietary Supervisor Assistant (DSA) confirmed that the sanitization sink solution log was incomplete, which meant it was unknown if the sanitization solution was within the appropriate range of 200-400 ppm. This lack of documentation indicates that the facility did not adhere to its policy and procedure for manual dishwashing, which requires testing and recording the concentration of the sanitizing solution. Additionally, the facility failed to maintain accurate records of cold storage temperatures, with missing entries noted for the PM shift on a specific date in October. The DSA acknowledged that the temperature logs were incomplete, which is crucial for ensuring that food is stored at safe temperatures to prevent spoilage. Furthermore, the Sanitizer Solution Log for the quaternary sanitizing solution used in the kitchen was also incomplete, with no records indicating that the solution was tested for concentration over an extended period. The Dietary Supervisor (DS) confirmed the missing entries and emphasized the importance of maintaining these logs to ensure the kitchen's sanitation practices were in line with the facility's policies.
Infection Control and Water Safety Deficiencies
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures, specifically in the cleaning and disinfection of resident-care items and equipment. This was observed when a Licensed Vocational Nurse (LVN) used a blood pressure cuff and monitor on two residents without cleaning and disinfecting the equipment between uses. The LVN admitted to not disinfecting the equipment after using it on the first resident and before using it on the second resident, acknowledging that this practice was necessary to prevent the spread of infection. The facility's policy, dated September 2022, clearly stated that reusable items should be cleaned and disinfected between residents. Additionally, the facility did not maintain a proper surveillance system to monitor its water system for Legionella, a potentially harmful bacteria. The Maintenance Supervisor revealed that there was no documentation of water testing for Legionella, as the results were stored on the previous administrator's phone, who was no longer employed. The Director of Nursing and the Infection Preventionist both emphasized the importance of testing for Legionella to ensure the safety of residents, staff, and visitors. The facility's policy, also dated September 2022, required specific measures to control the spread of Legionella, which were not being followed.
Ineffective Pest Control in Supply Room
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of a large, live cockroach in the supply room containing enteral nutrition and other food products. During an observation, a cockroach was seen on the floor under a metal storage shelf rack with boxes of canned enteral nutrition. The Infection Preventionist confirmed the presence of the cockroach and acknowledged that it should not be in the storage room due to the risk of contaminating food products and spreading disease. The facility's exterminator service reports indicated treatments were conducted on the exterior perimeter and kitchen areas, but not specifically in the storage rooms. The Maintenance Supervisor confirmed that the pest control personnel only visited at night and did not inspect or treat the storage rooms unless requested. The facility's policy and procedure documents indicated an ongoing pest control program and routine cleaning and pest control procedures, but these were not effectively implemented, leading to the deficiency.
Failure to Document Controlled Medication Administration and Discrepancies in Drug Records
Penalty
Summary
The facility failed to maintain professional standards of quality in medication management for a resident by not documenting the administration of Morphine Sulfate, a controlled medication, on the Control Drug Record. On a specific date, a Licensed Vocational Nurse (LVN) administered Morphine Sulfate to the resident but did not record this on the Control Drug Record, as confirmed by a Registered Nurse (RN) during an interview. This omission was against the facility's policy, which requires documentation to ensure accurate medication counts and prevent potential medication errors or diversion. Additionally, there was a discrepancy in the documentation of the physician's order and the volume of the medication vial on the resident's Control Drug Record. The record incorrectly indicated a different concentration and administration frequency than what was ordered by the physician. The RN acknowledged that the Controlled Drug Record contained incorrect instructions and that the nurse responsible for receiving the medication should have verified the physician's order and the delivery receipt to ensure accuracy. The facility's Director of Nursing (DON) and a pharmacist confirmed that the volume of Morphine Sulfate recorded was incorrect, and the medication was delivered in separate quantities on different dates. The facility's policy requires that each delivery be documented separately to prevent errors and potential diversion. The failure to adhere to these procedures resulted in inaccurate records, which could lead to medication errors and undetected diversion of controlled substances.
Failure to Provide Proper Footwear for Resident
Penalty
Summary
The facility failed to ensure proper footwear for a resident, identified as Resident 76, which had the potential to cause discomfort and increased the risk of falls and injuries. Resident 76 was admitted with diagnoses including diabetes mellitus and cellulitis of the right lower limb. The resident had moderate memory and cognitive impairment and required assistance with various activities of daily living. After a surgery in June 2024, Resident 76 was placed in a surgical shoe, but during a later observation, it was noted that the resident was using a pair of slippers with duct tape securing the Velcro strap, which was not safe. Interviews with the resident and staff revealed that the duct-taped slippers were used because the original post-op shoe was missing, and the slippers did not fit properly due to the bandaging on the resident's foot. The resident expressed discomfort and a desire for proper footwear to avoid getting the gauze dirty. The CNA and PT involved did not recognize the safety issue with the duct-taped slippers, and the PT admitted to not paying attention to the resident's footwear needs. The treatment nurse also failed to notice the inappropriate footwear during daily wound care. The resident's family member had attempted to address the footwear issue by purchasing slippers and modifying them with duct tape, but was unaware of the medical requirements for proper footwear. The facility's policies on foot care and fall risk management were not adhered to, as staff did not assess the resident's needs or provide appropriate footwear. The Director of Nursing acknowledged that the staff should have ensured the resident's comfort and safety by providing suitable footwear.
Incorrect LAL Mattress Setting for Resident
Penalty
Summary
The facility failed to ensure that a resident at risk for skin breakdown and pressure injuries received appropriate treatment and services to prevent skin breakdown. Specifically, the low air loss mattress (LAL Mattress) for a resident was incorrectly set for a body weight of 320 pounds, while the resident's actual weight was 185 pounds. This incorrect setting was observed during an inspection, and it was noted that the mattress should have been set for 200 pounds to properly distribute air and relieve pressure. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was at risk for developing or worsening pressure injuries due to the incorrect mattress setting. The facility's policy required monitoring of the LAL Mattress settings every shift, but this was not adhered to, leading to the deficiency. The treatment nurse confirmed the incorrect setting and acknowledged that it could increase the risk of further skin breakdown.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to provide adequate foot care for a resident, identified as Resident 45, who had long toenails and a fungal infection. Despite having a physician's order for podiatry care every 60-90 days, the resident did not receive the necessary treatment. The resident was documented as having refused podiatric treatment, but no alternative services were offered or provided by the facility to ensure foot care was maintained. This resulted in the resident experiencing pain and discomfort when his feet were touched. Resident 45, who was admitted with diagnoses including paraplegia and primary osteoarthritis, had intact cognition and required moderate assistance for personal hygiene. The resident's care plan indicated a need for assistance with activities of daily living, including grooming. However, the facility's staff did not follow up on the resident's refusal of podiatric care, and there was no documentation of an assessment to understand the reason for the refusal or to explain the risks and benefits of the treatment. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's foot care needs. A CNA noticed the long toenails but did not report it to the Charge Nurse, assuming the Social Service Director (SSD) would handle it. The SSD was unaware of the resident's refusal due to pain and did not conduct an interdisciplinary team meeting to address the issue. The Director of Nurses acknowledged that the staff should have assessed the resident's refusal and ensured that nail care was provided.
Incorrect Feeding Formula Administered to Resident
Penalty
Summary
The facility failed to administer the correct feeding formula to a resident, identified as Resident 28, who was dependent on gastrointestinal tube (GT) feeding. Resident 28 was admitted with diagnoses including dementia, protein-calories malnutrition, and dysphagia, and was ordered by a physician to receive Peptamen [NAME] PHGG or Vital AF 1.2 at a rate of 80 ml per hour for 20 hours. However, observations revealed that Peptamen AF, a different formula, was being administered instead. The Registered Dietician (RD) confirmed that Peptamen [NAME] PHGG and Peptamen AF are not the same, and the incorrect formula could lead to intolerance and other complications. Interviews with staff, including a Registered Nurse (RN) and the Director of Nurses (DON), revealed a misunderstanding regarding the equivalence of the formulas. The RN believed the two formulas were the same, while the DON acknowledged they were different and emphasized the need for a new physician order if an alternative formula was used. The facility's policy on enteral nutrition requires that the provider orders the nutrition based on the dietitian's recommendations, highlighting the importance of following the correct protocol to prevent potential adverse effects on the resident's health.
Failure to Properly Store Nebulizer Mask
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 55, by not adhering to professional standards of practice and the facility's policy and procedure. Specifically, the nebulizer mask used by Resident 55 was not stored in a plastic bag when not in use, as observed during a room inspection. This oversight was confirmed during an interview with the Infection Prevention Nurse, who stated that the nebulizer mask should be kept in a bag to prevent contamination. Resident 55 was admitted to the facility with diagnoses including a disorder of the lung and generalized anxiety disorder. The resident's cognitive skills for daily decision-making were intact, and they required limited assistance for activities of daily living. The resident had a physician's order for Ipratropium-Albuterol Nebu Solution to be administered via a nebulizer every four hours as needed for shortness of breath. The facility's policy, dated November 2011, outlined specific infection control measures for nebulizer use, including storing the circuit in a plastic bag between uses, which was not followed in this instance.
Deficiencies in Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to accurately and safely provide pharmaceutical services for a resident, specifically in handling Morphine Sulfate (MS), a controlled medication. The facility did not properly discard and destroy the remaining MS for the resident after it was discontinued, as per the facility's policy and procedure. The remaining MS vial was left in the narcotics drawer, and the Controlled Drug Record was incorrectly filed, leading to a discrepancy in the amount of MS that was supposed to be destroyed. The Director of Nurses (DON) was not informed of the remaining MS for destruction, which resulted in a potential risk for diversion of the controlled medication. Additionally, the facility failed to document the administration of MS on the resident's Control Drug Record on a specific date, despite it being recorded on the Medication Administration Record (MAR). This lack of documentation could lead to medication errors and discrepancies in the narcotic count. The facility also did not maintain accurate records of the MS received from the hospice pharmacy, which hindered the ability to reconcile the medication administered or destroyed. Furthermore, the facility did not ensure that nurses signed the Narcotic Medications Surveillance log after completing narcotic counts at the end of each shift. Multiple instances of unsigned sections on the surveillance log indicated that the narcotic counts were not consistently performed, increasing the risk of undetected diversion of controlled medications. The facility's policies and procedures for controlled substances and medication destruction were not adequately followed, contributing to these deficiencies.
Failure to Accommodate Resident's Dietary Preferences and Allergies
Penalty
Summary
The facility failed to provide meals that accommodated a resident's food preferences and allergies, specifically for a resident who was served tomato products and milk despite having a dislike for tomatoes and an allergy to milk. This resident, who was admitted with diagnoses including moderate protein-calorie malnutrition and gastro-esophageal reflux disease (GERD), expressed that her food preferences were not being considered, as she continued to receive meals containing these items. The resident's meal card clearly indicated her dislikes and allergies, yet these were not adhered to during meal service. During a dining observation, the resident was served a meal that included spaghetti with tomato sauce and chocolate ice cream, both of which were against her stated preferences and dietary needs. The registered nurse confirmed the oversight and removed the tray to request an alternative meal. The dietary supervisor explained the process for checking diet cards against meal trays, which involves multiple checks by tray line staff, the dietary supervisor or assistant, and the licensed nurse. However, this process failed in this instance, leading to the resident receiving inappropriate food items.
Failure to Implement Smoking Policy Leads to Unsupervised Smoking
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to establish and implement written policies and procedures to address noncompliance with the facility's smoking policy for eight residents who were smokers. This deficiency was identified through observation, interviews, and record reviews. The facility did not identify quality deficiencies related to noncompliance with the smoking policy, ensure effective oversight of the smoking area, or develop a system to obtain input from the Activity Director to address noncompliance. As a result, eight residents were observed smoking unsupervised during nonscheduled smoking times, with two residents possessing cigarette lighters, posing potential risks for accidental burns and fire hazards. Interviews revealed that the Director of Nurses (DON), who was also acting as the facility's Administrator, acknowledged the lack of a policy for addressing noncompliance with smoking. The Activity Staff (AS) reported being aware of the noncompliance but felt unable to enforce the policy due to residents' reactions. The new Activity Director (AD) confirmed the absence of a policy and the need for staff to follow existing guidelines. The DON admitted that the concern about noncompliance had been raised in past meetings but was not prioritized or addressed in the QAA meetings, leading to the observed deficiencies.
Failure to Maintain Functioning Call Light System
Penalty
Summary
The facility failed to provide and maintain a functioning call light system for one of the sampled residents, Resident 10. This deficiency was identified during an observation on October 21, 2024, when it was noted that there was no call light system in Resident 10's room. Resident 10 had been admitted to the facility with diagnoses including lack of coordination, chronic obstructive pulmonary disease (COPD), and cognitive communication deficit. The Minimum Data Set (MDS) assessment indicated that Resident 10 had severely impaired cognitive skills for daily decision-making and required extensive assistance for various activities, including bed mobility, transfer, toilet use, personal hygiene, and bathing. During the observation, a Certified Nursing Assistant (CNA) was unable to recall how long the call light had been missing but acknowledged the importance of having it within reach for emergencies. A Registered Nurse (RN) confirmed the absence of the call light and deemed it unacceptable, stating that she would follow up with maintenance. The facility's policy, revised in 2022, mandates that each resident should have a means to call staff directly for assistance from their bed, toileting, bathing facilities, and the floor. The lack of a functioning call light system for Resident 10 was a clear deviation from this policy.
Deficiencies in Sanitation and Pest Control
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by two main deficiencies. Firstly, the facility did not ensure that a resident's oxygen concentrator machine was clean. The resident, who had severe cognitive impairments and required substantial assistance with daily activities, was observed receiving oxygen from a concentrator that had a layer of accumulated white dust on it. The Licensed Vocational Nurse (LVN) acknowledged the dust and stated that it should have been cleaned to maintain a sanitary environment, but was unaware of how long it had been since the machine was last cleaned. Secondly, the facility failed to maintain effective pest control, as flies were observed in the dining room where residents were eating. Three residents, who had varying levels of cognitive impairment and required assistance with eating, were seen shooing away flies from their food. Staff members, including a Certified Nursing Assistant (CNA) and a Physical Therapy Assistant (PTA), also attempted to shoo away the flies. One resident reported that flies had been a problem for the past two months and that the facility had not addressed the issue despite complaints. The Infection Preventionist (IP) noted that the facility's proximity to a horse stable contributed to the fly problem. The facility's policies on pest control and maintaining a homelike environment were not adhered to, as the building was not kept free of insects, and residents were not provided with a clean and sanitary environment. These deficiencies had the potential to cause allergic reactions and food contamination, posing a risk of infection to the residents.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with federal regulations by accommodating more than four residents in five of its rooms, specifically rooms 32, 33, 34, and 35, each containing six beds. This was observed during a survey conducted on October 21, 2024. The Director of Nurses (DON) acknowledged the non-compliance and mentioned that the facility had a Room Variance Waiver in place and intended to request an additional waiver. Despite the waiver, the facility's policy from May 2017 stated that all resident rooms should accommodate no more than two residents, indicating a discrepancy between practice and policy. During observations and interviews with residents in the affected rooms, it was noted that residents did not express concerns about the space or their ability to move around. Residents reported being able to ambulate without difficulty and having enough space for their belongings. However, the facility's Client Accommodations Analysis confirmed the presence of more than four residents per room, and the facility's request for a room waiver indicated that the current arrangement did not adversely affect residents' health, safety, or well-being. The facility also outlined measures to ensure residents' needs were met, such as ensuring wheelchair accessibility and space for visitors and personal belongings.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in five out of thirty resident rooms, specifically rooms 32, 33, 34, and 35. This deficiency was identified during an entrance conference interview with the Director of Nurses (DON), who acknowledged that these rooms did not meet the federal regulation set by the Centers for Medicare & Medicaid Services (CMS). The facility had previously obtained a Room Variance Waiver for these rooms and intended to request an additional waiver. Despite the lack of space, the DON claimed there was no adverse effect on the health, safety, or wellbeing of the residents. Observations and interviews conducted in the affected rooms revealed that residents did not express concerns about the limited space. Residents were observed moving around their rooms without difficulty and stated they felt comfortable with the available space. The facility's Client Accommodations Analysis confirmed that these rooms provided only 72.33 square feet per resident, which is below the required standard. The facility's policy, dated May 2017, indicated that all bedrooms should meet federal and state requirements, including the provision of at least 80 square feet per resident in double rooms.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent and respond to the elopement of a resident with severely impaired cognition. The resident, who had diagnoses including schizoaffective disorder, HIV, and dysphagia, was not assessed or identified as at risk for unsafe wandering and elopement, despite exhibiting wandering behavior. The facility did not provide adequate supervision or develop a care plan to prevent the resident from wandering or eloping, as required by their policies. On the day of the incident, the resident was last seen in the front lobby by staff but was later discovered missing. The staff failed to announce the facility's emergency code for a missing resident, which would have alerted all staff to the situation. The facility did not conduct a thorough investigation into how the resident eloped, and there was no immediate notification to law enforcement or other necessary parties. Interviews with staff revealed that the resident was not considered at risk for elopement, and there were no interventions in place to monitor or supervise the resident. The facility's policies and procedures for assessing and managing residents at risk for elopement were not followed, leading to the resident's disappearance and the subsequent identification of an Immediate Jeopardy situation by the California Department of Public Health.
Removal Plan
- The facility initiated an investigation, notified law enforcement, residents responsible party, primary physician and CDPH.
- The facility contacted hospitals in the area to inquire if they have admitted the resident.
- Multiple staff members searched in the nearby areas including, parks, stores, shopping centers as well as neighboring areas.
- The facility will continue its efforts to search for the resident on a daily basis for 3 months which would include contacting law enforcement as well as local hospitals and additionally search the local area weekly for 3 months.
- The DON immediately initiated a review making sure that all residents are accurately reassessed, monitored, and supervised residents at risk of wandering behavior and elopement.
- Residents at risk for elopement are monitored and their whereabouts always accounted for and only three residents were identified in this category of which two of them have a wander guard and one of them was on a one-on-one monitoring until a wander guard can be placed on her.
- Sliding doors in Rooms B and C were reported to be opening to a width that a person could pass through. The maintenance supervisor immediately made appropriate adjustments by putting a stopper making sure the door does not open to a width that a person can pass through.
- The maintenance supervisor assessed the rest of the facility and made sure that there were no possible exit doors or windows that residents with risk of elopement could exit from by making sure that the alarms that are on them are working and that if they were to be opened the staff would be alerted.
- A scheduled 24 hour receptionist is in place to monitor the front doors.
- Additional monitoring of residents every 2 hours by the assigned nurse and reviewed by the shift charge nurse.
- Additional staff monitor implemented at the outside entrance of the facility from 7 am to 7pm and an alarm that cannot be easily removed without special tools will be activated at the facility's front door from 7pm to 7am. The Maintenance supervisor/ Designee will conduct daily audits making sure that they are working.
- The DON/ Designee initiated in-services on: How to accurately assess residents for risk of wandering behavior and elopement How to care for residents at risk for elopement, based on the elopement assessment the plan of care will be individualized How to monitor and supervise residents for wandering behavior and elopement to identify risk factors for each resident such as cognitive impairment, history of wandering and/or elopement and conducting elopement risk assessment upon admission quarterly and as needed.
- Ensuring residents at risk for elopement were monitored and their whereabouts were always accounted for, and a wander guard was placed on them or other measures such as a one on one monitoring.
- Staff respond promptly by the following: Charge nurse should be contacted right away and immediately do the following: Page Code Green. Assign staff members to search throughout the inside of the facility premises and search in the immediate outside vicinity. Verify whether or not the resident has gone out on pass or at an appointment. And immediately contact: Law enforcement, resident's family members, physician and CDPH (California Department of Public Health) within 2 hours.
- The maintenance supervisor was in serviced by the administrator in regard to the importance of making sure all sliding doors are only opening enough that a person can't pass through it. The maintenance supervisor/Designee will conduct daily checks for 3 months on the sliding doors, ensuring they are only opening enough that a person can't pass through it.
- Inservice was conducted to all supervisors in regard to properly investigating any incidents including interviewing staff, roommates, residents' family members or any other person that might be able to provide useful information.
- The DON/ Designee will conduct weekly audit logs making sure that residents are being accurately assessed for the risk of wandering behavior and elopement, residents at risk for elopement are monitored and their whereabouts always accounted for every 2 hours.
- The Director of Staffing Development (DSD) will conduct weekly Audits by asking random staff on how to care for residents that have been found to be at risk for elopement and that staff are responding promptly by calling out Code green per the facilities policy and procedures. The administrator will review on a daily basis from Monday through Friday for 3 months the previous days log for the additional monitoring staff.
- The administrator will conduct weekly checks on resident room sliding doors for 3 months making sure that they are functioning properly.
- The Administrator will conduct weekly checks on the door alarms for 3 months making sure that they are working properly.
- A Quality Assurance Program Improvement- (QAPI measures set by the facility to improve delivery of care at the facility) has been initiated in regard to ensuring that there is a system in place for residents who are at risk or maybe at risk for elopement, Elopement risk assessments, and elopement management.
- The administrator will conduct a weekly review of all investigations for three months making sure that incidents are being thoroughly investigated and include Interviews of staff, roommates, residents' family members or any other person that might be able to provide useful information.
- The results will be reviewed by the QA for further evaluation and recommendation if necessary.
Failure to Ensure Staff Competency Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure that three staff members had the necessary competencies and skills to manage residents with wandering behavior and those at risk for elopement. Specifically, a Licensed Vocational Nurse (LVN) did not attend in-service training for elopement and the facility's Code Green procedure, which is used to alert staff of a missing resident. The Director of Staffing Development (DSD) did not evaluate staff competencies after in-service training or when a resident eloped, and there were no clear instructions provided in the in-services about Code Green. The deficiency was highlighted by the case of a resident with severe cognitive impairment and a history of wandering, who eloped from the facility and remained missing. The resident's Elopement Evaluation form was incorrectly filled out, indicating the resident was not at risk for elopement, despite behaviors such as wandering into other residents' rooms and expressing a desire to go home. The facility's staff failed to develop a care plan with interventions to prevent the resident from wandering and eloping. Interviews with staff revealed a lack of adherence to procedures when the resident was discovered missing. The LVN and Certified Nursing Assistants (CNAs) panicked and forgot to announce Code Green, delaying the search and notification process. The Director of Nursing (DON) admitted to instructing staff to copy a previous, incorrect elopement evaluation form, and the facility's policy and procedures for elopement were not effectively implemented, contributing to the resident's elopement.
Inappropriate Resident Discharge Without Physician's Order
Penalty
Summary
The facility failed to ensure that a resident was appropriately transferred or discharged in accordance with its policy and procedure. The resident, who was cognitively intact and required assistance with daily activities, was discharged to law enforcement and subsequently to their family without a physician's order, discharge medications, or appropriate discharge planning. This resulted in the resident not receiving prescribed medications for six days, which could lead to medical complications. The incident began when two police officers arrived at the facility, claiming the resident had been reported missing. The Licensed Vocational Nurse (LVN) on duty allowed the resident to leave with the officers without consulting the attending physician or ensuring the resident's medical needs were addressed. The Director of Nurses (DON) and the LVN acknowledged the unusual nature of the situation but did not take steps to ensure a safe and planned discharge, such as obtaining a physician's order or coordinating with the resident's family. Interviews with the resident, family member, and facility staff revealed a lack of communication and planning. The resident was not informed about the importance of their medications or the implications of leaving the facility. The family was unaware of the resident's medical needs upon discharge, and the facility did not follow up promptly to ensure the resident's safety. The facility's policy required a physician's order for discharges and proper documentation, which was not adhered to in this case.
Failure to Address Medication Refusal in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was refusing to take Risperidone, an antipsychotic medication. The resident, who was admitted with diagnoses including immunodeficiency, schizophrenia, and generalized anxiety disorder, was cognitively intact and required assistance with daily activities. Despite having a physician's order for Risperidone to be administered twice daily, the medication was not given for several days due to the resident's refusal. The care plan in place did not address the resident's refusal of the medication, focusing instead on non-compliance with other aspects such as wearing a mask and personal hygiene. Interviews with the resident, an LVN, and the DON revealed that the resident refused the medication because it was prescribed during a previous hospital stay and she had not yet seen a psychiatrist at the facility. The LVN and DON acknowledged the importance of a care plan tailored to the resident's needs, especially given her psychiatric diagnosis. However, the facility did not create a care plan to address the medication refusal, which was confirmed by the DON during a review of the resident's records. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, which was not adhered to in this case.
Failure to Monitor Behavior in Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure proper behavior monitoring for a resident diagnosed with schizophrenia, as per their policy and procedure titled Behavior, Mood and Cognition. The resident was admitted with diagnoses including schizophrenia and generalized anxiety disorder, and was prescribed Risperidone for schizoaffective disorder. However, the facility did not monitor the specific behaviors associated with the resident's condition from the time of admission until several days later, despite the facility's protocol requiring such monitoring. Interviews with facility staff, including an LVN and the DON, revealed that the resident's behavior was not monitored as required, which could have led to a delay in physician notification and treatment. The facility's policy mandates that nursing staff document and inform the physician about changes in a resident's mental status, behavior, and cognition, but this was not adhered to in the case of the resident in question. The oversight was acknowledged by the DON, who admitted to forgetting about the behavior monitoring requirement.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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