Hyde Park Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 6520 West Blvd., Los Angeles, California 90043
- CMS Provider Number
- 056435
- Inspections on file
- 62
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 26 (1 serious)
Citation history
Health deficiencies cited at Hyde Park Healthcare Center during CMS and state inspections, most recent first.
A resident with schizophrenia, bipolar disorder, and anxiety became acutely agitated, threw a phone toward staff, and tossed meal items, but staff did not document a change-of-condition assessment, notify the physician, revise the care plan, or implement enhanced monitoring or one-to-one supervision as required by existing behavior and abuse-prevention care plans and facility policies. Despite care plan directives to assess triggers, remove the resident from overstimulating environments, and transfer to a GACH for further evaluation when agitation escalated, these interventions were not carried out or documented. Later that day, the same resident pushed another cognitively impaired resident with dementia, depression, and psychosis in the hallway, causing the second resident to strike his face on a handrail and sustain a right eyebrow laceration requiring sutures at a GACH. The deficiency centers on the facility’s failure to follow its own care plans and change-of-condition and abuse-prevention policies, leading to resident-to-resident physical abuse and injury.
A resident with cerebral palsy, schizoaffective disorder, dysphagia, severe cognitive impairment, and documented swallowing difficulties experienced an aspiration episode while eating, after which the physician ordered a downgrade to a minced and moist (IDDSI Level 5) diet and an SLP evaluation confirmed swallowing deficits and recommended the same texture. However, the resident’s care plan remained outdated, continuing to direct CNAs, LPNs, and RNs to provide a regular easy-to-chew (IDDSI Level 7) diet instead of the newly ordered texture, contrary to facility policy requiring care plan review and revision with changes in condition and treatment.
A resident with encephalopathy, dementia, and schizophrenia had severe cognitive impairment and a care plan requiring staff to obtain and monitor labs as ordered and report results to the MD. A CBC ordered by the physician in one month was not drawn, with no documentation in progress notes that it was completed, attempted, refused, or that the MD was notified. After the resident later developed cough and chest congestion, another CBC was ordered to be drawn within three days, but records again showed no evidence that the test was done, attempted, refused, or communicated to the MD. An LVN and the DON confirmed that the CBC orders were not carried out and that appropriate follow-up with the lab vendor and physician did not occur.
A resident with severe cognitive impairment, multiple comorbidities, and documented fall risk experienced four falls, including unwitnessed events and falls resulting in lacerations, skin tears, bleeding from the mouth, and transfers to the hospital. The care plans in place focused on general assistance with ambulation and transfers, neuro checks, and broad directives to determine and address causative factors, but did not include specific, individualized fall-prevention interventions. After each fall, the facility did not hold IDT meetings with the attending physician or consult the pharmacist, despite policies requiring IDT-driven, person-centered care planning and medication review for fall risk. The DON acknowledged that the existing and revised interventions were insufficient to prevent further falls.
A resident with severe cognitive impairment and physical disabilities, who was conserved and dependent on staff for mobility and lower body dressing, was sexually assaulted by another resident with a documented history of sexually inappropriate behavior and wandering. Hospital records prior to admission had identified this behavior and led to precautions, and the admitting RN received a report noting the sexually inappropriate behavior. However, the behavior was not included in the admission summary, no behavior-focused care plan or monitoring was developed, and there was no documentation that staff beyond the admitting RN and RD were aware of the risk. The resident with sexually inappropriate behavior was observed entering the victim’s room multiple times and making flirtatious gestures before the incident. On the day of the event, a roommate summoned staff, and a CNA found the male resident on top of the cognitively impaired resident behind a drawn curtain, with both engaged in intercourse and the victim’s garments pulled down. The victim was nonverbal, assumed a fetal position, and later had genital ecchymosis documented on a sexual assault exam, while the male resident stated he had intercourse because the other resident did not object. These events demonstrate the facility’s failure to follow its abuse prevention, resident safety, and comprehensive care plan policies by not assessing, care planning, and monitoring a resident with known sexually inappropriate behavior.
A resident with COPD and type 2 DM reported that a tall male staff member of African descent with dark skin and an accent exposed his genitals and had unprotected sexual intercourse with her during nighttime hours before a hospitalization. She stated she reported the allegation to the ADON upon her return. The ADON and other leaders attempted to identify the alleged perpetrator primarily from memory and concluded no staff matched the description, without systematically using staffing records or fully considering the reported date and time. The AADM, responsible for the investigation, interviewed the resident and one CNA he believed matched the description but did not ensure interviews were conducted with all potentially involved male staff working the relevant shifts, and he submitted a conclusion letter to the SA with an incorrect incident date and unsupported statements that interviews with current and former male staff had been completed. Staffing records showed multiple male staff on duty during the relevant nights, yet there was no documentation of interviews, no evidence that any staff were suspended or placed on investigative leave, and no thorough, timely, and documented investigation as required by the facility’s abuse and protection policies.
A resident with COPD and other respiratory disorders, who had cognitive impairment and required substantial assistance with ADLs, had a physician order for O2 at 3 L/min every shift that did not specify whether it was to be given continuously or PRN. Nursing staff did not clarify the frequency with the physician and did not ensure that an O2 concentrator or tubing was available in the resident’s room, despite the resident reporting no access to O2 since readmission. An RN and the DON acknowledged the lack of clarification and the absence of immediately available O2, which was inconsistent with facility policies requiring complete respiratory orders and provision of O2 support when indicated.
Staff entered telephone and other medical orders under the attending physician’s name instead of the actual prescriber, including MDs and NPs covering for the attending. One physician reported that when her medical team phoned in orders, staff consistently used her name because the EMR did not list other team members as selectable ordering providers. Another physician confirmed that the EMR only allowed orders to be entered under the attending MD, making it difficult to determine which covering MD actually issued an order. Facility policy required medication telephone orders to be countersigned by the prescriber, but the documentation process did not accurately reflect the true ordering provider.
The facility failed to report an allegation of resident-on-resident physical abuse to CDPH as required. A resident with diabetes, hypertension, and documented need for extensive assistance reported to an LVN and the assistant administrator that another resident had been hitting her in the stomach since admission. Despite this allegation, there was no Change of Condition entry or progress note documenting the report for either resident, and no report was made to CDPH. The assistant administrator later acknowledged receiving the allegation from the LVN and not reporting it, even though facility policy and federal requirements direct that all abuse allegations be immediately reported to CDPH, the Ombudsman, and law enforcement using the SOC 341 form.
A resident with DM and HTN, who required supervision to maximal assistance with ADLs, was admitted without obtaining admission consent from the court-appointed conservator, despite facility policy requiring consent from the resident or responsible party and presentation of surrogate documentation at or before admission. The conservator later reported she had not been informed of the transfer and had not authorized the admission, and the Admission Coordinator acknowledged that the facility’s admission policy was not followed.
A resident with seizure-related diagnoses and documented decision-making capacity was transferred multiple times to an acute care hospital while on bed-hold status, but the facility failed to provide the required written bed-hold notifications at each transfer as mandated by its Bed-Hold policy. Staff interviews and record review showed only one bed-hold agreement signed at admission, despite census records indicating additional bed-hold periods, and nursing and administrative staff acknowledged that written information about the bed-hold option should have been provided and filed for each transfer.
Two residents with seizure disorders did not receive anticonvulsant medications as ordered, and required monitoring was not completed. One resident with a seizure history and conversion disorder missed scheduled doses of Keppra, with documentation showing a dose was not given due to waiting for pharmacy delivery and no record of follow-up, and another dose not given after return from hospital without explanation. PRN Ativan ordered for seizures was not documented as administered during a seizure event, and there were no orders or documentation of Keppra blood levels despite facility policy. A second resident with epilepsy missed two morning doses of Depakote because the medication was not available in the cart, with no documented physician notification or explanation in the progress notes. These actions and omissions did not follow the facility’s policies for medication administration and seizure disorder management.
A resident with multiple chronic conditions, including DM and hypertension, was admitted from a hospital with older discharge paperwork, and the admitting nurse did not obtain or clarify admission orders with a physician at the time of admission. Instead, an LVN later entered multiple medication orders based on the outdated hospital discharge list without contacting the attending MD or on-call coverage, and no evidence was found that any MD reviewed or authorized these admission orders. Facility policies required that residents be admitted only on written orders from the attending MD and that all medication orders be signed by a licensed prescriber, but this process was not followed, resulting in unverified admission orders for the resident.
A resident with multiple chronic conditions, including DM, HTN, GERD, hypothyroidism, hyperlipidemia, glaucoma, bipolar disorder, schizophrenia, and depression, was admitted and did not receive scheduled night medications or timely morning medications because admission orders were not properly entered or verified by an MD. Nursing staff reported that the admitting nurse failed to enter physician orders, that no follow-up call was made to the MD on night shift, and that they were instructed by an administrator to enter orders based on hospital discharge paperwork without contacting the MD. As a result, critical medications such as insulin, antihypertensives, psychotropics, and other chronic disease medications were either missed or administered several hours late.
A resident with cognitive impairment and psychiatric diagnoses was pushed to the floor by another resident with similar impairments, resulting in a head laceration that required hospital treatment. The incident was witnessed by staff, and records showed both residents had histories of agitation and required assistance with daily activities. Facility policy prohibits such abuse, but the event still occurred, leading to physical harm.
Licensed nurses did not follow up with the pharmacy to obtain a physician-ordered antipsychotic medication for a resident with a history of aggressive behavior, resulting in the resident missing the medication for eight days. During this period, the resident exhibited aggression and pushed another resident, causing a head injury that required hospital treatment. Documentation showed repeated notations of the medication being unavailable, and the pharmacy confirmed no request was received until after the incident.
A resident with severe cognitive impairment and multiple psychiatric diagnoses did not receive Seroquel 25 mg as ordered for eight consecutive days due to delays in medication procurement and administration. During this period, the resident was involved in an altercation that resulted in injury to another resident. The DON confirmed the medication was not obtained or administered as ordered, constituting a significant medication error.
Nursing staff failed to accurately document the administration of a psychotropic medication for a resident with severe cognitive impairment, recording doses as given or refused when the medication was not available in the facility. Pharmacy records confirmed the medication was not delivered for over a week after the order, and staff did not follow up to ensure timely access. This resulted in inaccurate medical records that did not reflect the actual care provided.
A resident with multiple psychiatric and cognitive diagnoses, including schizophrenia and suicidal ideation, was not properly assessed for elopement risk despite exhibiting unsafe behaviors and a change in condition. The facility failed to follow its own policies for reassessment and supervision, did not act on a physician's recommendation for immediate psychiatric intervention, and did not obtain a complete history of prior elopement. As a result, the resident eloped and was not found.
A staff member failed to use required personal protective equipment, specifically a gown, while providing ADL care to a resident with a stage 4 pressure ulcer who was under Enhanced Barrier Precautions due to an open wound. The resident was totally dependent on staff and had severe cognitive impairment. Facility policy and staff interviews confirmed that gown and glove use is required for such care to prevent the spread of multi-drug-resistant organisms.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
The facility did not limit PRN antipsychotic medication orders to 14 days for a resident with bipolar disorder and schizophrenia, and failed to monitor or document behaviors and adverse effects related to Ativan use for another resident with dementia and anxiety. The DON confirmed that required monitoring and documentation were not completed, and care plans addressing these issues were not developed.
The facility did not complete and resubmit PASARR Level I screenings or refer for Level II evaluations for two residents with mental health diagnoses, including anxiety disorder, schizophrenia, and major depressive disorder. In both cases, the residents' mental health conditions and use of psychotropic medications were not accurately reflected in the PASARR process, and the required notifications and referrals to the state mental health authority were not made, contrary to facility policy and regulatory requirements.
Two residents with significant mental health diagnoses did not have individualized care plans addressing their conditions or the use of psychotropic medications. One resident with anxiety and Ativan use lacked a care plan and monitoring for medication effects, while another with schizophrenia had no care plan for the diagnosis, contrary to facility policy. The DON confirmed these omissions and acknowledged the required processes were not followed.
A resident with severe cognitive impairment and ongoing tobacco use did not receive required quarterly smoking and safety assessments, as only the initial assessment was completed. Additionally, the fire extinguisher on the smoking patio was locked and not accessible to staff, with the key held by maintenance, leaving the area without immediate fire safety equipment.
The facility did not ensure that non-narcotic medication destruction logs in one medication room were properly completed, as required signatures and dates were missing from all reviewed records. The DON confirmed that nurses responsible for medication disposition failed to sign the logs, resulting in incomplete documentation.
Three medication administration errors were observed, resulting in an error rate above 5%. Two residents received incorrect medication doses and formulations, including a higher dose of calcium carbonate, a multivitamin with minerals instead of without, and a full tablet of Seroquel instead of a half-tablet. An LVN acknowledged not verifying medication labels against physician orders, leading to these errors.
Surveyors found that unopened latanoprost eye drops and two unopened Lantus insulin pens for three residents were stored at room temperature in medication carts instead of being refrigerated as required by manufacturer instructions. LVNs confirmed the improper storage and acknowledged the need for refrigeration prior to use, in accordance with facility policy.
A resident with multiple medical conditions was not included in care plan meetings despite being able to communicate and expressing a desire to participate. Staff interviews and record reviews confirmed that no care conference was held with the resident or her representative, and required documentation was incomplete.
A resident who was totally dependent on staff and had an indwelling catheter was observed with an exposed foley catheter drainage bag, as no privacy bag was applied. Both an RN and the DON confirmed that using a privacy bag is standard practice to maintain dignity, and facility policy requires care that respects resident privacy.
A resident with severe cognitive impairment and multiple chronic conditions did not have their Discharge MDS assessment transmitted to CMS within the required 14-day timeframe. The MDSN confirmed the delay, and facility policy requiring timely submission was not followed.
A resident admitted with schizophrenia, major depressive disorder, anxiety, and other mood disorders did not have a required Level 1 PASARR screening completed upon admission. The DON confirmed the omission and noted that facility policy requires such screenings for all potential residents, but the process was not followed in this instance.
A resident admitted with a history of stroke, dysphagia, and liver cirrhosis did not have a baseline care plan developed within 48 hours of admission, despite requiring moderate assistance with daily care. Facility staff confirmed that the interdisciplinary team did not complete the required interim care plan as outlined in facility policy.
A resident with a Stage 4 pressure ulcer and multiple medical conditions was observed lying on a regular mattress despite a physician's order for a low air loss mattress. The DON confirmed the absence of the required mattress and that no such mattresses had been ordered recently, contrary to facility policy for pressure injury care.
A resident with an indwelling catheter and a history of urinary tract infection was not referred to urology for evaluation as ordered upon hospital discharge. Despite documentation in the resident's records and facility policies requiring such referrals, the appointment was not scheduled by the nursing staff, resulting in a delay of necessary care.
A CNA's personnel file lacked both the initial and annual competency checklists as required by facility policy. The Director of Staff Development confirmed that these documents were missing and should have been completed to ensure staff competency.
A resident with bipolar disorder and schizophrenia received PRN Zyprexa for periods longer than 14 days after the facility failed to act on a consultant pharmacist's recommendation to limit the order duration. The DON confirmed that the facility did not follow policy requiring PRN antipsychotic orders to be limited to 14 days and did not document any response to the pharmacist's recommendation.
A nurse administered a full tablet of Seroquel instead of the prescribed half tablet to a resident with schizophrenia, after failing to reconcile a discrepancy between the physician's order and the pharmacy label. The medication packaging and label did not reflect the updated dose, and the nurse did not verify the correct dosage before administration.
A resident with epilepsy did not receive a physician-ordered Levetiracetam blood level every three months as required. The omission was confirmed by an LVN during record review, despite the care plan indicating the need for lab monitoring and reporting of abnormal results. The resident had multiple diagnoses, including epilepsy, and required moderate assistance with daily activities.
A resident with cognitive impairment and multiple diagnoses had a stat x-ray ordered for left leg and foot pain, but the x-ray results were not accessible or filed in the medical record. Nursing staff confirmed the records were incomplete, and there was no documentation of communication with the physician or follow-up with the x-ray provider. The DON stated the results were received and given to staff, but could not explain their absence from the record or provide evidence of physician notification.
A LVN failed to disinfect a shared blood pressure cuff before and after use during medication administration for two residents, despite facility policy requiring cleaning after each use. The LVN acknowledged not following the disinfection protocol during an interview.
Two residents with moderate cognitive impairment were involved in an altercation, with one alleging that the other tripped him, resulting in a fall. The facility did not report the incident to CDPH within the required two-hour timeframe, as staff were not made aware of the allegation until two days after the event. This delay led to a late investigation and increased risk for further abuse.
Multiple rooms were found to have less than the required 80 square feet of living space per resident, with three beds placed in rooms measuring 215 square feet. An AADM acknowledged that the limited space could make it difficult for nursing staff to provide care.
A resident with schizophrenia, major depressive disorder, and diabetes was discharged without their knowledge or consent, and against medical advice, after leaving the facility without completing the required sign-out process. Despite being identified as an elopement risk and having specific physician orders regarding absences, the facility was unable to confirm the resident's whereabouts or safety and processed the discharge without proper documentation or contact with the resident's emergency contact.
Two residents with significant medical needs were found to have dirty bed linens that had not been changed daily or when soiled, as required by facility policy. Staff interviews confirmed the linens were unclean and not changed as expected, and the DON acknowledged the importance of daily linen changes for infection control and resident dignity.
A resident with paraplegia and cognitive impairment fell and sustained a fracture due to a CNA's failure to use a two-person assist with a Hoyer Lift, as required by the care plan. The CNA attempted the transfer alone, leading to the resident's fall and subsequent hospitalization.
A resident with paraplegia and cognitive impairment fell during a transfer assisted by a CNA using a Hoyer Lift, resulting in a hip fracture. The facility did not report the incident to CDPH, assuming the GACH would do so. The facility's policy required reporting such events, but it was not followed.
The facility failed to maintain a safe and homelike environment for four residents, as flies were observed in their rooms, causing feelings of discomfort and dehumanization. Residents with various mental health and physical conditions reported the presence of flies, which had been an issue for several days. Staff acknowledged the potential for disease spread, but there was a delay in addressing the problem, contrary to the facility's policies on maintaining a homelike environment and pest control.
A resident with a history of depression and anxiety reported missing personal belongings, but the facility failed to file a grievance or conduct an investigation, violating the resident's rights. The Social Services Director was informed but did not document the incident or follow the grievance process, as confirmed by the Director of Nursing.
A resident's call light was not plugged in or within reach, contrary to facility policy. The resident, with a history of depressive disorder and anxiety, confirmed the call light was missing. Staff, including an LVN and CNA, acknowledged the importance of call lights for resident safety, but failed to ensure its availability, leading to a deficiency.
Failure to Manage Escalating Behaviors Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to implement required assessments and interventions in response to escalating behaviors. On the morning of 4/5/2026 at 8:10 a.m., Resident 5, who had diagnoses including schizophrenia, bipolar disorder, and anxiety, became agitated at the nurse’s station, threw the facility phone toward a nurse’s head without provocation, then went to his room, removed a breakfast tray from the cart, and threw it onto the floor while stating, “I want to go to the hospital now.” Progress notes documented that Resident 5 was encouraged to self-regulate using deep breathing and that staff attempted to provide a safe environment with frequent safety checks, but there was no documentation of a Change of Condition (COC) assessment, no physician notification, and no new care plan or revision of the existing care plan after this behavioral outburst. The facility’s records did not show that Resident 5 was monitored for behavioral outbursts after 8:10 a.m. Resident 5 had an existing care plan titled “Risk for harm: self-directed or other-directed,” with a goal that the resident would not harm self or others and interventions including administering prescribed medications and notifying the provider if the resident posed a potential threat to injure others. Another care plan, “Resident does not harm self or others. New behavior potentially causing harm to self or others,” directed staff to monitor for signs and symptoms of agitation. A third care plan, “Increased Agitation manifested by throwing object at staff and yelling,” included interventions to assess for triggers, notify the physician of persistent or escalating behaviors, remove the resident from overstimulating environments when agitation began, and transfer the resident to a general acute care hospital (GACH) for further evaluation and treatment. Despite these written interventions, staff did not document that they assessed for triggers, notified the physician, removed Resident 5 from an overstimulating environment, initiated transfer to a GACH, or implemented one-to-one supervision after the 8:10 a.m. incident. Interviews with CNA 2, LVN 4, RN 1, the DON, and the Assistant Administrator confirmed that Resident 5 was agitated that morning, threw items including breakfast trays and a water pitcher, and that there was no additional documentation of continuous monitoring, physician notification, or care plan changes following the initial outburst. Later that same day, at approximately 11:45 a.m., Resident 3, who had diagnoses including unspecified dementia, depression, and unspecified psychosis and who had cognitive impairment requiring partial/moderate assistance with ADLs and supervision or touching assistance with transfers and bed mobility, was walking in the hallway when Resident 5 walked behind him and pushed him from behind. Resident 3’s right side of the face struck the hallway handrail, resulting in a cut to the right eyebrow with a small amount of blood. A COC dated 4/5/2026 at 11:45 a.m. documented that Resident 3 was walking in the corridor when Resident 5 pushed him, and that 911 was called and Resident 3 was transferred to a GACH for further evaluation and treatment, where he received six stitches in his right eyebrow. On 4/8/2026, observation showed Resident 3’s right eye was purple and swollen with steri-strips on the right eyebrow, and Resident 3 stated he did not know what happened to his eye. A separate COC for Resident 5 at 12:00 p.m. documented that Resident 5 stated Resident 3 was “evil” and “deserved it,” and that a 5150 transfer was recommended for behavioral issues. The facility’s Abuse and Neglect Prohibition Policy required the facility to identify, correct, and intervene in situations where abuse is more likely to occur by assessing, care planning, and monitoring residents with behaviors that may lead to conflict, including those with a history of aggressive behaviors. The failure to follow these policies and care plan interventions, and to promptly assess and respond to Resident 5’s escalating agitation, led to Resident 5 pushing Resident 3 to the floor and causing injury. The facility’s policies titled “Comprehensive Plan of Care” and “Change of Condition” required that care plans include interventions to manage risk factors and be revised as changes occur, and that the attending physician be promptly notified of changes in a resident’s mental condition, with use of the SBAR tool and development of a care plan for the change of condition. Nurse’s notes were to document changes in medical or mental condition. Interviews with RN 1 and the DON indicated that when Resident 5 became agitated, nurses should have assessed the situation, attempted to calm the resident, remained with him, notified the physician, obtained necessary medications, conducted frequent rounds (at least every 30 minutes), and considered one-to-one supervision. The Assistant Administrator stated he was not aware of the 8:10 a.m. incident but acknowledged that, based on the progress notes, Resident 5 had been agitated and should have been placed on one-to-one or sitter supervision for the safety of other residents. The lack of documented assessment, monitoring, physician notification, care plan revision, and implementation of the facility’s abuse prevention and change-of-condition policies after the initial behavioral incident constituted the actions and inactions that led to the physical abuse of Resident 3 by Resident 5.
Failure to Update Care Plan After Diet Texture Change Following Aspiration Event
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s comprehensive care plan after a physician-ordered change in diet texture following an aspiration event. The resident had multiple diagnoses, including cerebral palsy, schizoaffective disorder, dysphagia, metabolic encephalopathy, seizures, protein-calorie malnutrition, hypothyroidism, schizophrenia, anxiety, and psychosis. The admission record and H&P documented that the resident was not self-responsible, could not make medical decisions, and had a conservator. The MDS showed severe cognitive impairment, short- and long-term memory problems, and a need for moderate assistance with eating, with documented issues of losing liquids/solids from the mouth and coughing or choking during meals or when swallowing medications. On a specified date, a Change of Condition (COC) documented that the resident experienced an episode of aspiration while eating, with coughing, difficulty clearing the throat after swallowing, and shortness of breath, and that this condition had not occurred previously. The COC indicated the primary physician recommended downgrading the resident’s diet. Physician orders dated the same day changed the diet to minced and moist/IDDSI Level 5 texture. The following day, an SLP evaluation and plan of treatment documented anterior-to-posterior transit delay, decreased bolus formation, and a tendency for the resident to overstuff her mouth, and recommended a minced and moist texture as tolerated, with any advanced diet texture trials to be provided only through the SLP. Despite these changes, the resident’s existing care plan, originally dated several months earlier, still directed CNAs, LPNs, and RNs to provide and serve a regular, easy-to-chew/IDDSI Level 7 diet. During interviews and concurrent record reviews, an LVN confirmed that the resident’s coughing and shortness of breath indicated a potential aspiration event and that the physician had ordered a diet change to prevent further choking and aspiration, stating that the care plan should have been updated to reflect the new orders. The SLP also stated that the resident’s care plan interventions were not updated to reflect the new physician-ordered diet texture. The facility’s policy on Comprehensive Plan of Care required that the comprehensive care plan address individual needs, include interventions to manage risk factors, and be reviewed and revised by the interdisciplinary team as changes in the resident’s care and treatment occur, including in response to changes in physical or functional status.
Failure to Complete and Communicate Ordered CBC Labs for a Resident
Penalty
Summary
The facility failed to meet professional standards of quality by not ensuring that physician-ordered Complete Blood Count (CBC) laboratory tests were obtained for one resident. The resident was admitted with encephalopathy, dementia, and schizophrenia, and had severe cognitive impairment documented on the MDS, with limited ability to understand or be understood and no indication of rejecting care. The resident’s care plan for nutritional problems directed nursing and dietary staff to obtain and monitor laboratory work as ordered, report results to the physician, and follow up as indicated. A physician order dated 2/8/2026 directed that a CBC be drawn, but review of progress notes for February 2026 showed no indication that the CBC was completed, attempted, or refused, and no documentation that the physician was notified that the CBC was not done. On 3/5/2026, a change of condition was documented when the resident developed cough with chest congestion, and the physician again ordered a CBC. A subsequent physician order dated 3/6/2026 specified that the CBC was to be drawn one time within three days. Review of progress notes from 3/1/2026 through 3/11/2026 showed no indication that this CBC was completed, attempted, or refused, and no documentation that the physician was notified that the ordered CBC was not done. During interviews, an LVN confirmed that neither the February nor March CBC orders were carried out within the required time frames and that there was no documentation of attempts, refusals, or physician notification. The DON also confirmed that the CBC orders were not performed and that staff should have contacted the lab vendor and notified the physician. The facility’s policy on physician notification indicated that physicians must be notified when laboratory results fall outside clinical reference ranges.
Failure to Implement Effective Fall-Prevention Interventions and Post-Fall IDT Review
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate fall-prevention interventions and post-fall management for one resident identified as being at risk for falls. The resident had multiple diagnoses, including chronic pulmonary edema, cirrhosis of the liver, and morbid obesity, and was documented on the MDS as having short-term memory problems and severely impaired cognitive skills for daily decision-making. Functionally, the resident required substantial assistance with toileting, lower body dressing, transfers, and walking, and used a wheelchair with partial to moderate assistance for mobility. A Fall Risk Evaluation dated 10/17/2025 identified the resident as at risk for falls, and the care plan for risk of falls included general interventions such as assisting with ambulation and transfers, utilizing therapy recommendations, determining transfer ability, and initiating fall risk precautions if the resident was at risk. Despite these identified risks, the resident experienced four falls after admission: an unwitnessed fall on 12/27/2025 with a reported headache that led to an emergency room transfer; an unwitnessed fall on 1/23/2026 resulting in a laceration above the right eyebrow and a skin tear on the right forearm; a fall on 2/18/2026 where the resident was found lying on the floor on the right side; and another fall on 2/21/2026 where the resident was found on the floor between the bed and tray table with bleeding in the mouth and confusion, leading to transfer to a general acute care hospital. Care plans related to impaired physical mobility and actual injury from the first unwitnessed fall focused on neuro checks, physician notification, pain assessment, and hospital transfer, and later added a general directive to determine and address causative factors of the fall. After the fourth fall, additional broad interventions were documented, such as anticipating and meeting needs, ensuring call light within reach, appropriate footwear, following the fall protocol, reviewing past falls to determine causes, and educating the resident and IDT. The facility did not conduct post-fall IDT meetings with the primary physician or consult the pharmacist after any of the four falls, despite facility policies requiring IDT involvement and physician and pharmacist input in developing and revising comprehensive, person-centered care plans and fall-prevention interventions. The DON acknowledged awareness of the resident’s falls and stated that staff should have implemented new interventions such as rounding and assisting the resident as needed, and further stated that the interventions in the resident’s care plan would not prevent a fall and that the revised interventions would not prevent another fall. Facility policies on Person Centered Care Plan, Fall Prevention Program, and Comprehensive Plan of Care required identification of resident-specific risks and causes, development of realistic and specific goals and approaches, implementation of precautions according to the fall prevention program, and periodic review and revision of the care plan by the IDT, including the attending physician and consultant pharmacist. These policy requirements were not followed for this resident following the repeated fall incidents.
Failure to Assess, Care Plan, and Monitor Resident With Known Sexually Inappropriate Behavior Resulting in Sexual Assault of a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse and Neglect Prohibition Policy and related safety policies, resulting in a resident with severe cognitive impairment being sexually assaulted by another resident with known sexually inappropriate behaviors. The cognitively impaired resident had spastic quadriplegic cerebral palsy, depression, schizoaffective disorder, and was conserved, with an MDS showing severe cognitive impairment and need for staff assistance with mobility and lower body dressing. On the date of the incident, progress notes documented that this resident was found lying in bed with lower garments down and did not respond when asked if she was in pain or knew what had happened. A change of condition assessment noted that a CNA had informed the charge nurse that a male resident was in the room, but the assessment did not document what occurred prior to the residents being separated or specify the details of the vaginal exam performed. The male resident involved had a documented history of sexually inappropriate behavior prior to admission. Hospital records from a recent stay indicated he had confusion, frequent wandering, and a history of depression, bipolar disorder, and schizophrenia, and that he had displayed sexually inappropriate behavior, including masturbating while looking at a CNA, leading to placement on precautions for sexually inappropriate behavior. A facility document summarizing the nursing report at admission showed that the admitting RN was informed of this sexually inappropriate behavior. However, the admission summary completed by that RN did not include the sexually inappropriate behavior or any interventions to address it, and there was no care plan or behavior monitoring documented in the resident’s medical record to address this risk. Multiple observations and interviews described the events leading to and surrounding the assault. The cognitively intact roommate reported that the male resident had come into their room multiple times before the incident, made flirtatious faces at the cognitively impaired resident, and that she had yelled at him to leave. On the day of the incident, the roommate ran into the hallway and requested staff assistance. A CNA entered the room quietly, heard moaning, saw shoes and jeans at the foot of the bed, and upon pulling back the curtain observed the male resident on top of the cognitively impaired resident, with both facing each other and actively engaged in sexual intercourse; the male resident then jumped off and ran out. The cognitively impaired resident’s brief and pants were pulled down to her knees, and she curled into a fetal position and refused to talk. Subsequent hospital sexual assault examination records documented that staff and law enforcement reported the male resident was forcing penile-vaginal penetration, and the exam found brown ecchymosis on the left medial anterior labia minora, with a sexual assault kit collected and STI prophylaxis and emergency contraception provided. The male resident later told staff and hospital providers that he had intercourse because the other resident did not object and acknowledged she did not give consent. The facility’s own policies required assessment, care planning, and monitoring of residents with behaviors that could lead to conflict or abuse, including wandering into others’ rooms and sexually aggressive behavior, and required the IDT to identify behavioral safety risks and develop resident-centered care plans. The dietician, who reviewed the admission paperwork and saw documentation of the male resident’s sexually inappropriate behavior, added this behavior as a problem in a nutrition care plan but did not notify other staff or develop behavior-related interventions, and the care plan interventions addressed only nutritional risks. The DON and ADON later acknowledged that the admitting RN knew of the sexually inappropriate behavior and that no care plan, behavior monitoring, or enhanced monitoring of the resident’s whereabouts was implemented, and that there was no documentation that staff beyond the admitting RN and RD were aware of the behavior. This lack of interdisciplinary communication, failure to incorporate known sexually inappropriate behavior into the comprehensive plan of care, and failure to monitor and manage the resident’s wandering and sexual behavior constituted noncompliance with the facility’s Abuse and Neglect Prohibition Policy, Protection of Resident policy, Resident Safety policy, and Comprehensive Plan of Care policy, and led to the sexual assault of the cognitively impaired resident.
Failure to Thoroughly Investigate Alleged Staff-to-Resident Sexual Misconduct
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of staff-to-resident sexual misconduct involving Resident 4. Resident 4, who had COPD and type 2 diabetes mellitus, was assessed on a recent MDS as having some difficulty with daily decision making in new situations but without inattention, disorganized thinking, or altered level of consciousness. Resident 4 reported that during nighttime hours, on the night before her most recent hospitalization, a tall male staff member of African descent with dark skin and an accent exposed his genitals, placed his penis on her hand, and then engaged in unprotected sexual intercourse with her in her bed. Resident 4 stated she reported this alleged encounter to staff upon her return from the hospital and identified the ADON as the first person she informed. The ADON acknowledged that Resident 4 reported the alleged sexual encounter and provided a description of the alleged perpetrator as tall, of African descent, with dark skin and an accent. The ADON stated she attempted to identify the alleged perpetrator by recalling male staff characteristics from memory and concluded that no one matched the description, without using staffing records or other objective data. The DSS similarly stated that Resident 4 described the alleged perpetrator as an African male and that there were no male staff who matched this description. The AADM, who was responsible for the investigation, reported that he interviewed Resident 4 and one CNA (CNA 3), whom he felt matched the description, but he did not take into account Resident 4’s report of the date and time of the incident to identify other potential staff. The DSD, who was supposed to conduct additional staff interviews, stated that as of several days after the allegation was reported, she had not interviewed any male staff matching the resident’s description who were working on or around the date of the alleged incident. The AADM submitted a conclusion letter to the State Agency indicating that the investigation was complete, that the alleged incident occurred on a date that did not correctly correspond to the resident’s hospitalization, and that no staff matched the resident’s description or had knowledge of the incident. The AADM later acknowledged that the incident date in the letter was incorrect and that he had assumed the alleged perpetrator had been terminated based solely on the resident’s statement that she had not seen the staff member since the incident, without confirming this through records. He also acknowledged that he did not verify that the DSD had completed staff interviews and that there were no documented interviews to demonstrate that an investigation had been conducted, despite the conclusion letter stating that interviews with current and former male staff had been done. Staffing assignments for the relevant night shifts showed multiple male staff, including those assigned to the resident’s care, but there was no documentation that these individuals were interviewed. Facility policies required prompt, thorough, and documented investigations of abuse allegations, including interviewing individuals who may have relevant information and suspending accused staff, but the investigation into Resident 4’s allegation was incomplete and not thoroughly documented as required. The facility’s own Follow-Up Investigation Report stated that a payroll report of all male staff was generated and that only one person fit the description, but the report did not specify what actions were taken regarding that staff member. The same report’s sections on interviews with alleged perpetrators and the conclusion stated that no one had any knowledge of the incident and that no one fit the description, despite the AADM’s admission that he had not confirmed that interviews were completed and could not provide documentation of such interviews. Additionally, the facility’s policies on Protection of Resident, Abuse – Reporting and Investigations, and Abuse and Neglect Prohibition Policy required that investigations be initiated within 24 hours, that they be thoroughly documented on the facility’s investigation form, and that involved or accused staff be placed on investigative leave or suspended until the investigation results were reviewed by the Administrator. These policy requirements were not met in the handling of Resident 4’s allegation, resulting in a deficient practice related to the facility’s response to alleged staff-to-resident sexual misconduct.
Failure to Clarify and Implement Oxygen Order for Resident With COPD
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care and services consistent with professional standards of practice for a resident with COPD and other respiratory disorders. During an observation in the resident’s room, the resident was seen sitting in a wheelchair without oxygen in use, and there was no oxygen concentrator or tubing present. The resident reported having COPD, sometimes experiencing shortness of breath, and stated that since being readmitted to the facility, no oxygen tank or tubing had been provided. Record review showed the resident had diagnoses including COPD, a respiratory disorder, and diabetes mellitus, and the MDS indicated cognitive impairment and a need for substantial/maximal assistance with ADLs. Review of the physician’s orders dated 1/9/2026 showed an order for oxygen at 3 L/min every shift related to COPD, but the order did not specify whether oxygen should be administered continuously or as needed. RN 1 acknowledged that the order lacked clarification on frequency and stated it was important to clarify the order with the physician and that an oxygen concentrator should have been available in the resident’s room for immediate use until clarification was obtained. The DON confirmed that the resident had a physician’s order for oxygen and that it was essential to follow physician orders, noting the resident could be at risk of respiratory distress if oxygen was not available for immediate use. Facility policies on oxygen administration and physician orders for respiratory modalities required provision of oxygen support when indicated and that all physician orders include modality, dosage, frequency, duration, and treatment diagnosis, which was not followed in this case.
Improper Documentation of Ordering Physician for Telephone and Medical Orders
Penalty
Summary
Facility staff entered telephone and other medical orders under the attending physician’s name rather than under the actual prescriber’s name, contrary to accepted standards and the facility’s own policy. During interview, one physician (MD1) reported that when telephone orders were given by members of her medical team (MDs, NPs), facility staff would document the orders using her name as the ordering physician. MD1 stated she had been informed that the facility’s electronic medical record system did not include the names of the other medical team members as options for the ordering provider. Another physician (MD2) confirmed that the computer program used for order entry only allowed selection of the attending physician’s name and did not allow the ordering MD to enter orders under their own name, making it difficult to identify which covering MD actually gave the order. Review of the facility’s Pharmaceutical Services Policy and Procedure Manual, dated 1/2025, showed that medication telephone orders were required to be countersigned by the prescriber. This practice resulted in difficulty identifying the ordering physician’s name in the medical record and had the potential to mislead the healthcare system and create potential for fraud, as documented by the surveyors.
Failure to Report Resident-on-Resident Abuse Allegation to CDPH
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of resident-on-resident physical abuse to the California Department of Public Health (CDPH). One resident (Resident 4), who was admitted with diabetes mellitus and hypertension, had documentation in a History and Physical dated 12/12/2025 indicating a lack of capacity to understand and make decisions, while a Minimum Data Set (MDS) dated 12/14/2025 indicated the resident was able to understand and be understood by others and required varying levels of assistance with activities of daily living and mobility. Despite these documented needs and cognitive findings, there was no Change of Condition (COC) entry or progress note from 12/11/2025 to 12/16/2025 reflecting any allegation that another resident had been hitting this resident, nor any indication that such an allegation was reported to CDPH. During an interview on 12/16/2025 at 11:00 a.m. at nurse’s station 1, Resident 4 stated that another resident (Resident 5) had been hitting her in the stomach since her admission to the facility, and she repeated this allegation. Licensed Vocational Nurse (LVN 2) and the Assistant Administrator (AADM) were present during this interview, and LVN 2 reported Resident 4’s statement to the AADM at that time. However, the clinical record for Resident 4 did not contain documentation of this allegation as a COC or in progress notes, and there was no documentation that the allegation was reported to CDPH as required. Resident 5, who was also admitted with diabetes mellitus and hypertension and had an H&P dated 10/2/2025 indicating capacity to understand and make decisions, had an MDS showing that she was usually able to understand and be understood and required assistance with multiple activities of daily living and transfers. A review of Resident 5’s clinical records from 12/11/2025 to 12/16/2025 showed no COC or progress note documenting any allegation that she had hit Resident 4, and no indication that such an allegation was reported to CDPH. In a subsequent interview on 12/31/2025 at 1:00 p.m., the AADM stated that on 12/16/2025 at 11:30 a.m., LVN 2 had reported the allegation that Resident 5 had been hitting Resident 4 in the stomach since admission, and acknowledged that he did not report the incident to CDPH, despite facility policy and federal law requiring that all abuse allegations be reported to CDPH, the Ombudsman, and the police department. The facility’s policy titled “Reporting Guidance & Timelines for Abuse & injuries of Unknown Origin,” dated 6/2022, states that alleged violations related to abuse are to be reported immediately using the SOC 341 form.
Failure to Obtain Required Admission Consent From Resident’s Conservator
Penalty
Summary
The deficiency involves the facility’s failure to obtain admission consent in accordance with its policy and procedure titled “admission to the Facility.” One resident was admitted on a specified date with diagnoses including diabetes mellitus and hypertension. The resident’s History and Physical dated 12/12/2025 documented that the resident did not have the capacity to understand and make decisions, while the MDS dated 12/14/2025 indicated the resident was able to understand and be understood by others and required varying levels of assistance with ADLs, including supervision, moderate assistance, and maximal assistance for mobility and self-care tasks. Despite the resident’s documented need for assistance and questions about decision-making capacity, the facility proceeded with admission without obtaining consent from the resident or the responsible party. During an interview, the resident’s family member stated she was the court-appointed conservator and reported that the prior facility did not inform her that the resident was being transferred and that she did not give the admitting facility permission to take the resident. In a concurrent interview and record review, the Admission Coordinator acknowledged that the facility’s policy was not followed when the conservator’s consent was not obtained prior to admission and stated that the conservator’s admission consent should have been obtained to ensure the resident’s and conservator’s wishes were respected. Review of the facility’s admission policy dated 1/2023 showed that residents are to be admitted only upon written order of the attending physician and with the consent of the resident or responsible party, and that identifying paperwork for any appointed surrogate or representative must be presented prior to or upon admission. These requirements were not met in this case.
Failure to Provide Required Bed-Hold Notices at Time of Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold notifications to a resident at the time of multiple transfers to an acute care hospital, as required by its own Bed-Hold policy and federal and state guidelines. The resident was originally admitted and later readmitted to the facility, with diagnoses including seizures and conversion disorder with seizures. A History and Physical dated 12/2/2025 documented that the resident had the capacity to understand and make decisions, and a Minimum Data Set dated 12/4/2025 showed the resident required partial/moderate assistance with ADLs and certain mobility tasks. The facility’s Daily Census indicated the resident was on bed-hold on several dates when transferred out, and the Admission Coordinator stated the resident should have signed bed-hold notices for each of these transfers, in addition to the admission, with copies filed in the medical record. Record review and staff interviews confirmed that only one bed-hold agreement, signed on 12/1/2025, was present in the resident’s file, and there were no additional bed-hold notices for subsequent transfers. The facility’s Bed-Hold policy, dated 12/2016, required written notification of the bed-hold option upon admission and at the time of transfer to a hospital or therapeutic leave, specifying the duration of the bed-hold, sending a copy with the resident at transfer, and providing written notice to family or representative within 24 hours in case of emergency transfer. The LVN and Interim DON acknowledged that, according to this policy, residents who were transferred should receive written information about the option to exercise the bed-hold policy at each transfer, and that the absence of additional bed-hold notices in the resident’s file meant the facility did not follow its policy. The report states this failure had the potential for the resident not to exercise the option to use the facility’s bed-hold policy and lose their bed at the facility.
Failure to Administer and Monitor Anticonvulsant Therapy for Residents With Seizure Disorders
Penalty
Summary
The facility failed to ensure seizure medications were administered according to professional standards for two residents with seizure disorders. One resident with a history of seizures and conversion disorder was ordered Levetiracetam (Keppra) 1000 mg orally every 12 hours. The Medication Administration Record (MAR) for that month showed missed doses at 9 a.m. on one date and 9 p.m. on the following date. An order administration note documented that the 9 a.m. dose was not given because the facility was waiting for the medication to be delivered, and there was no documentation that staff followed up with the pharmacy to ensure timely delivery. Nursing progress notes showed the resident was sent to a general acute care hospital later that afternoon due to a seizure and was readmitted the next evening, yet there was no documentation explaining why the 9 p.m. dose of Keppra was not administered upon readmission. For the same resident, the MAR showed a PRN order for Lorazepam (Ativan) 2 mg/mL IM every five minutes as needed for seizures, up to three doses, but there was no indication that Ativan was administered when the resident experienced the seizure that led to transfer to the hospital. Review of active and discontinued orders for the month showed no orders for monitoring Keppra blood levels. Interviews with LVNs revealed that Keppra doses were not documented when given, one dose was charted on the wrong date, and there was no documented evidence of pharmacy follow-up when the medication was reportedly unavailable. The interim DON stated that Keppra levels should have been obtained on initial assessment and readmission per facility policy, but there was no record of any Keppra levels for this resident. A second resident with epilepsy, described as intractable without status epilepticus, was ordered Divalproex Sodium (Depakote) 750 mg twice daily. Review of the MAR for the same month showed that the 9 a.m. doses on two consecutive days were not administered. An LVN stated that these doses were not given because the Depakote was not available in the medication cart. Another LVN stated that staff should have called the physician for orders when Depakote was not available and that the resident should have received the missed doses to prevent seizures. Review of the resident’s progress notes for those dates did not show documentation explaining the missed doses. Facility policies on medication administration and care for residents with seizure disorders required timely administration, immediate documentation on the MAR, and assessment and documentation of anticonvulsant blood levels, which were not followed in these cases.
Failure to Obtain and Verify Physician Admission Orders for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to obtain and verify physician admission orders for a newly admitted resident as required by its admission and pharmaceutical services policies. The resident was admitted with diagnoses including diabetes mellitus and hypertension. The admission record showed the resident was admitted from a general acute care hospital with discharge paperwork dated several weeks prior to the admission date. Progress notes documented that the admitting physician’s orders were not entered at the time of admission because the orders needed clarification from the attending physician, and that the hospital’s updated discharge records for the actual admission date could not be located. Subsequent review of the resident’s record showed telephone orders entered the day after admission listing multiple medications and treatments, including allopurinol, aripiprazole, atorvastatin, carvedilol, famotidine, insulin glargine, regular insulin per sliding scale, latanoprost, levothyroxine, lisinopril, olanzapine, quetiapine, trazodone, and glucagon. An LVN reported that the admitting nurse did not enter physician orders at the time of admission and could not recall why, and that no follow-up call was made to the attending physician because physicians were perceived as not answering facility calls on night shift. The LVN stated that the medication list used for the physician orders entered was taken from the resident’s older hospital discharge paperwork and that these orders were not verified with the attending physician. Interviews with the attending physician and another physician indicated that neither had given admission orders for the resident on the admission date and that there was no record of admission orders being sent for verification. The attending physician described the usual process of photographing transfer orders and sending them to the physician for review and verbal acceptance or declination, but could not find any evidence this occurred for this resident. Both physicians stated it was important for physicians to review admission orders to prevent medication errors. Review of facility policies confirmed that residents were to be admitted only upon written order of the attending physician and that medication orders must be signed by a licensed physician authorized to prescribe medications. The facility’s failure to follow these procedures resulted in the resident’s admission orders not being verified by a physician.
Failure to Obtain Timely MD Verification and Administer Admission Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely physician verification and administration of admission medications for a newly admitted resident. The resident was admitted with diagnoses including DM, hypertension, gout, GERD, hypothyroidism, hyperlipidemia, glaucoma, bipolar disorder, schizophrenia, and depression. The resident’s H&P indicated a lack of capacity to understand and make decisions, while the MDS documented that the resident could understand and be understood and required varying levels of assistance from supervision to maximal assistance for ADLs and mobility. Telephone orders dated the early morning after admission listed multiple medications, including antihypertensives, insulin (both glargine and sliding scale regular insulin), psychotropic medications, and other chronic disease medications. Record review and staff interviews showed that the resident’s admission date and time were documented, but the resident did not receive night medications due on the evening of admission, including carvedilol, insulin glargine, and trazodone, because the medication orders were not verified by the prescribing physician. The LVN interviewed stated that the resident’s medication administration history showed that all 9 a.m. medications the following day were not given until 12:21 p.m., over three hours late. These medications included aripiprazole, famotidine, sliding scale insulin, lisinopril, olanzapine, quetiapine, and trazodone. The LVN explained that the delay and missed doses were related to the lack of physician verification of the admission orders. Further interviews revealed that the admitting nurse did not enter any physician orders at the time of admission and could not recall why the admission orders were not entered. Another LVN stated she did not make a follow-up call to the physician because physicians do not answer facility calls on night shift and that she had been told by an administrator to enter physician orders without calling the physician, as night shift nurses enter orders without contacting MDs. The medication list used for the physician orders was taken from the resident’s hospital discharge paperwork. The attending physician later stated she had not given admission orders for the resident on the date of admission and emphasized the importance of MD review of admission orders to prevent medication errors, duplicate drugs, or contraindicated medications.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident pushed another to the floor, resulting in a head injury that required hospital evaluation and treatment. The incident occurred when a resident with a history of major depressive disorder, type 2 diabetes mellitus, and paranoid schizophrenia was talking with another resident in the hallway. Another resident, who had diagnoses including bipolar disorder, Alzheimer's disease, schizophrenia, and Parkinson's disease, approached and pushed the first resident to the floor without provocation. The injured resident sustained a 1.0-inch laceration to the back of the head, which required two staples at a general acute care hospital. Record reviews indicated that both residents involved had moderately impaired cognitive skills and required assistance with activities of daily living. The resident who was pushed had a documented history of agitation and aggressive behaviors, and was noted to lack the capacity to make reasonable decisions, requiring redirection. The resident who pushed also had a history of agitation and aggressive behaviors, lacked capacity for medical decisions, and required redirection. The incident was witnessed by staff, who observed the push and responded by providing immediate first aid and calling emergency services. The facility's policy prohibits abuse, mistreatment, and neglect, and specifies that residents who threaten or attack others should be removed from the situation. Despite these policies, the incident occurred, resulting in physical harm to a resident. The deficiency was identified through interviews, record reviews, and direct observation of the incident and its aftermath.
Failure to Obtain and Administer Ordered Antipsychotic Medication Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that licensed nurses followed up with the contracted pharmacy regarding a physician's order for Seroquel 25 mg three times daily for a resident with diagnoses including bipolar disorder, Alzheimer's disease, schizophrenia, and Parkinson's disease. The order was written to manage the resident's aggressive behavior, but the medication was not obtained or administered for eight days. Documentation in the Medication Administration Record (MAR) repeatedly indicated that the medication was not available, and progress notes showed ongoing delays attributed to awaiting pharmacy delivery. The pharmacy confirmed that no medication request was received for the order, and the medication was not delivered until eight days after the order was written. During this period, the resident did not receive the prescribed Seroquel, which was intended to manage symptoms of aggression and angry outbursts. On the eighth day without the medication, the resident exhibited aggressive behavior by pushing another resident, resulting in the second resident falling and sustaining a 1.0-inch laceration to the back of the head. The injured resident required evaluation and treatment at a general acute care hospital, where two staples were placed to close the wound. Interviews with staff and review of records confirmed that the medication omission was not promptly addressed, and the pharmacy was not contacted in a timely manner to resolve the issue. The facility's policy on medication errors defines omission of a vital medication as a medication error and requires assessment, documentation, and reporting to the physician and pharmacy. Despite this policy, the omission persisted for eight days, and the resident's care plan, which included administration of psychotropic medications as ordered, was not followed. The Director of Nursing acknowledged that staff failed to ensure the medication was obtained and administered as ordered, and that this failure could have contributed to the aggressive incident and resulting injury.
Failure to Administer Ordered Antipsychotic Medication Resulting in Resident Altercation
Penalty
Summary
The facility failed to ensure that Seroquel 25 mg, an antipsychotic medication, was obtained, available, and administered as ordered for a resident with multiple psychiatric and neurological diagnoses, including bipolar disorder, Alzheimer's disease, schizophrenia, and Parkinson's disease. Despite a physician's order for Seroquel 25 mg three times daily starting on 11/24/2025, the medication was not requested from the pharmacy until 12/1/2025 and was not received by the facility until 12/2/2025. As a result, the resident missed eight consecutive days of the prescribed medication. During this period without the ordered antipsychotic, the resident, who had severely impaired cognitive skills and required assistance with daily living activities, was involved in a resident-to-resident altercation that resulted in injury to another resident. The DON confirmed that nursing staff did not ensure timely procurement and administration of the medication, and acknowledged that the absence of Seroquel could have contributed to the escalation in the resident's behavior. Facility policy defined the omission of a prescribed medication as a medication error.
Falsification of Medication Administration Records for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that registered nurses (RNs) and licensed vocational nurses (LVNs) accurately documented the administration of a psychotropic medication, Seroquel, for a resident with multiple diagnoses including bipolar disorder, Alzheimer's disease, schizophrenia, and Parkinson's disease. The resident was assessed as having severely impaired cognitive skills and lacked capacity to make medical decisions. The physician ordered Seroquel to be administered three times daily for behavior management, and the care plan directed staff to administer the medication as ordered. Review of the Medication Administration Records (MARs) for November and December showed that staff documented Seroquel as administered or refused on multiple occasions when the medication was not actually available in the facility. Progress notes indicated that the medication was not administered at several scheduled times due to pending pharmacy delivery, yet the MARs reflected administration or refusal entries. Interviews with nursing staff confirmed that they documented administration or refusal despite the medication not being present, and did not follow up with the pharmacy to ensure timely delivery. Pharmacy records and interviews revealed that the pharmacy did not receive a request for Seroquel until several days after the order was written, and the medication was not delivered until more than a week later. The facility's policy required medication to be administered and documented in accordance with physician orders and good nursing practice, but this was not followed. As a result, the resident's medical records were inaccurate and did not reflect the actual care provided or the resident's clinical condition during the period in question.
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Assessment and Supervision
Penalty
Summary
A facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent the elopement of a resident with significant psychiatric and cognitive impairments. The resident in question had diagnoses including schizophrenia, suicidal ideations, bipolar disorder, major depressive disorder, and diabetes mellitus. Despite these conditions, the facility's elopement risk assessment did not account for the resident's cognitive level or history of elopement, and the assessment inaccurately determined that the resident was not at risk for elopement. The resident had demonstrated poor judgment and unsafe behaviors, including an attempt to ingest hand sanitizer, which was documented as a change of condition requiring reassessment and increased supervision. Following the resident's attempt to ingest hand sanitizer and escalating agitation, the physician recommended a 5150 hold for immediate psychiatric evaluation and stabilization. However, the facility did not follow this recommendation in a timely manner, nor did it reassess the resident's risk for wandering and elopement after the change in condition. The care plan called for close monitoring and hourly documentation, but the resident was last observed walking in the hallway and was later found missing during staff rounds. The facility's policies required identification, assessment, and appropriate interventions for residents at risk of elopement, but these procedures were not followed. Interviews with facility staff and review of records confirmed that the elopement risk assessment was conducted incorrectly, and that the resident should have been placed on one-to-one supervision and transferred to a general acute care hospital as recommended. The facility also failed to obtain a complete history of the resident's prior elopement behavior from family or conservators, which contributed to the inaccurate risk assessment. As a result of these failures, the resident eloped from the facility and was not found as of the time of the report.
Removal Plan
- Elopement Code was activated (Code Green) to alert staff to immediately search for Resident 1 inside and outside the facility and its vicinity.
- Acute hospitals were contacted to check for Resident 1's presence.
- The elopement involving Resident 1 was reported to Los Angeles Police Department (LAPD), California Department of Public Health (CDPH), and the local Long-Term Care (LTC) Ombudsman.
- The DON and/or DSD initiated an in-service for facility nursing staff and Interdisciplinary Team (IDT) every shift on F689 Free of Accident Hazards/ Supervision and Monitoring focused on Elopement.
- The IDT which included Social Worker (SW), DON and Activities Director (AD) conducted record review and reassessed 65 out of 65 residents for wandering and elopement.
- A total of 4 residents were identified as high risk for elopement. The IDT updated the plan of care for all 4 residents.
- The facility's DON and Director of Staff Development (DSD) provided Licensed Vocational Nurse (LVN), door monitor Certified Nursing Assistant (CNA) and CNA assigned to Resident 1 one on one education on F689 Free of Accident Hazards/ Supervision and Monitoring focused on Elopement.
- The DON and/or DSD provided staff in-service on regular rounding for patient safety and daily safety huddles.
- The facility's DSD observed CNAs during their shift when caring for 4 of 4 residents who were at high risk for wandering and with inappropriate behavior. Residents observed receiving adequate supervision accordingly.
- IDT initiated review of records and reassessment of 4 of 4 residents who were at high risk for elopement and wandering and plan of care updated.
- The Maintenance Director installed door chimes to notify staff of entry or exit in addition to the door monitor CNA, which was stationed at the entrance/exit 24 hours per day, 7 days per week.
- The Director of Medical Records/Designee conducted an audit of residents' behavior, elopement and wandering episode to identify residents who had changes in condition, need monitoring and transfer to General Acute Care Hospital (GACH) for behavior management, through record review of assessments and physician's order.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency occurred when staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with a stage 4 pressure ulcer. The resident, who had diagnoses including hepatic encephalopathy, COPD, and dementia, was totally dependent on staff for activities of daily living (ADLs) such as eating, oral hygiene, and toileting. The resident's medical records indicated severely impaired cognitive skills and an inability to make medical decisions. During an observation, a Certified Nurse Assistant (CNA) was seen providing ADL care to the resident without wearing a gown, despite the resident being on EBP due to the presence of an open wound. Interviews with the CNA, Director of Staff Development (DSD), and Director of Nursing (DON) confirmed that EBP protocols require staff to wear gloves, mask, and gown when providing care to residents with wounds or medical devices to prevent the spread of multi-drug-resistant organisms (MDROs). The CNA acknowledged forgetting to use a gown during care. Review of the facility's policy confirmed that gown and glove use is required for high-contact care activities under EBP, such as dressing, bathing, and toileting.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. No additional details about the specific resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Limit PRN Antipsychotic Orders and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that PRN (as needed) orders for antipsychotic medications were limited to a 14-day duration for one resident. Specifically, a resident with a diagnosis of bipolar disorder and schizophrenia had active PRN orders for Zyprexa that exceeded the 14-day limit on two occasions, with one order lasting 24 days and another lasting 16 days. The Director of Nursing (DON) confirmed that the facility did not adhere to the policy requiring PRN antipsychotic orders to be limited to 14 days, as the rationale for use may change within that period. Additionally, the facility did not monitor or document the target behavior or adverse effects related to the use of Ativan for another resident diagnosed with dementia and anxiety. The resident was prescribed Ativan for anxiety manifested by an inability to relax, but there was no documentation in the Medication Administration Record (MAR) to record or quantify the behavior or monitor for adverse effects. There were also no physician orders or care plans addressing the monitoring of the behavior or adverse effects related to Ativan use for this resident. The facility's policy on psychoactive medication management requires that PRN antipsychotic orders be limited to 14 days and that nursing staff document behaviors and adverse reactions in the MAR. The policy also specifies that behaviors and possible adverse drug reactions should be monitored every shift. The facility did not follow these requirements for the two residents involved, as confirmed by the DON during interviews.
Failure to Complete and Resubmit PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to complete and resubmit the Preadmission Screening and Resident Review (PASARR) Level I screening and refer for a Level II evaluation when indicated for two residents. For one resident, the admission record showed diagnoses including metabolic encephalopathy, dysphagia, and dementia, with a psychiatric evaluation confirming an anxiety disorder. The resident was prescribed Lorazepam, a psychotropic medication, for anxiety. Despite these findings, the PASARR Level I completed by the transferring hospital did not reflect the mental health diagnosis or psychotropic medication use, and the facility did not resubmit a new PASARR Level I to indicate the updated diagnosis or refer for a Level II evaluation as required. Another resident was admitted with diagnoses of schizophrenia and major depressive disorder. The PASARR Level I application for this resident incorrectly indicated that there was no mental health disorder, and therefore, a Level II PASARR was not initiated. The DON acknowledged that the PASARR should have been resubmitted to reflect the accurate diagnoses, but this was not done. The DON also noted that PASARRs are to be completed before or within 24 hours of admission, but she had not been given access to process them. Facility policy and the PASRR reference manual require prompt notification and re-evaluation by the state mental health authority if there is a significant change in a resident's mental condition or if a mental illness is identified. In both cases, the facility did not comply with these requirements, resulting in the failure to ensure appropriate assessment and referral for specialized mental health services for the affected residents.
Failure to Develop Comprehensive Care Plans for Residents with Mental Health Diagnoses and Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents with specific mental health diagnoses and medication needs. For one resident with a diagnosis of anxiety and behaviors of inability to relax, the facility did not create a care plan addressing these issues or the use of Ativan, an anti-anxiety medication. There was no documentation or monitoring of the resident's behaviors or potential adverse effects related to Ativan use in the Medication Administration Record (MAR), and no physician orders were in place to monitor for these concerns. The Director of Nursing (DON) confirmed that the lack of a care plan and monitoring prevented the care team from properly evaluating the ongoing need for the medication. Additionally, another resident with a diagnosis of schizophrenia did not have a care plan developed to address this condition, despite facility policy requiring individualized care plans for residents with behavioral and psychoactive medication needs. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and a need for partial assistance with activities of daily living. The DON acknowledged that care plans should be initiated upon admission or change of condition and that the absence of a care plan for schizophrenia could result in improper care.
Failure to Complete Smoking Assessments and Ensure Accessible Fire Safety Equipment
Penalty
Summary
A review of a resident's records revealed that the facility failed to complete required quarterly smoking and safety assessments for a resident with severe cognitive impairment, dementia, and ongoing tobacco use. The resident's Minimum Data Set indicated a need for supervision with daily activities and current tobacco use, yet only an initial smoking and safety assessment was completed, with no follow-up assessments performed as required by facility policy. The MDS nurse confirmed responsibility for these assessments and acknowledged the omission, which is necessary to ensure appropriate interventions and care planning for residents who smoke. Additionally, during an observation on the smoking patio, the fire extinguisher was found locked in a box, and the staff present did not have access to the key. The activity assistant stated that in the event of a fire, the extinguisher would not be accessible, and she would have to leave the area to retrieve another extinguisher from the kitchen. This lack of immediate access to fire safety equipment on the smoking patio was confirmed by staff and is contrary to facility policy requiring accessible fire safety measures in smoking areas.
Incomplete Non-Narcotic Medication Destruction Logs
Penalty
Summary
The facility failed to maintain complete records for the destruction of non-narcotic medications in the Station 1 Medication Room. During an observation, it was found that the non-narcotic medication destruction logs, kept in a three-ring binder, did not contain signatures from licensed staff or witnesses, nor did they indicate who was responsible for completing the medication destruction. A review of the Facility Medication Destruction Form records from early March to late June revealed that none of the available records had the required signatures or dates, making it impossible to determine which nurses completed the disposition of medications. An interview with the DON confirmed that the destruction logs for non-narcotic medications were incomplete, as the nurses responsible for performing the disposition on the overnight shift failed to sign off on any of the available logs after completing the destructions. The facility's policy, revised in July 2022, requires that a non-controlled medication disposition log be used for documentation, including the date of disposition and signatures of the required witnesses, but these requirements were not met.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Errors
Penalty
Summary
The facility failed to ensure that its medication error rate remained below five percent, as required. During medication administration observations, three errors were identified out of 26 opportunities, resulting in an error rate of 11.54%. These errors involved two residents who were administered medications that did not match their physician's orders. Specifically, one resident received an incorrect dose of calcium carbonate, and another received both the wrong formulation of a multivitamin and an incorrect dose of Seroquel. For the first resident, the nurse administered a 750 mg tablet of calcium carbonate instead of the prescribed 500 mg dose. The resident had a history of paranoid schizophrenia and was capable of making her own medical decisions. The error was observed during the medication pass, and the nurse later acknowledged administering the incorrect dose. The second resident, who also had a diagnosis of schizophrenia and was capable of medical decision-making, was given a multivitamin with minerals instead of the prescribed formulation without minerals. Additionally, the nurse administered a full 50 mg tablet of Seroquel instead of the ordered half-tablet dose. The nurse stated that she did not verify the medication label against the physician's order and failed to notice a discrepancy between the pharmacy label and the current order, which contributed to the administration of the incorrect dose and formulation.
Failure to Store Medications per Manufacturer Instructions
Penalty
Summary
Surveyors observed that the facility failed to store certain medications according to manufacturer instructions. Specifically, one unopened vial of latanoprost eye drops intended for a resident was found stored at room temperature in a medication cart, rather than in the refrigerator as required by the product labeling. During an interview, the LVN confirmed that unopened latanoprost should be refrigerated and acknowledged that improper storage could affect the medication's effectiveness. Additionally, two unopened Lantus insulin pens for two other residents were found stored at room temperature in a medication cart, instead of being refrigerated as specified by the manufacturer. The LVN responsible for these medications confirmed that unopened insulin pens are supposed to be refrigerated until use and that improper storage or labeling could compromise their effectiveness. A review of the facility's medication storage policy indicated that medications and biologicals must be stored safely and properly, following manufacturer recommendations, including refrigeration when required.
Resident Not Included in Care Plan Meeting
Penalty
Summary
The facility failed to ensure that a resident participated in the development and implementation of her person-centered plan of care. The resident, who had diagnoses including cerebral infarction, dysphagia, and liver cirrhosis, was admitted to the facility and was assessed as having the ability to express ideas and understand others. Documentation indicated that the resident required moderate assistance with daily activities and expressed a desire to participate in assessment and goal setting. However, there was no evidence that the resident or her representative attended any care plan meetings, and the Multidisciplinary Care Conference Note was incomplete with no documentation of attendance. Interviews with the resident confirmed that she had never met with facility staff to discuss her condition or medications. Staff interviews, including those with the Social Service Director, MDS Nurse, and Director of Nursing, acknowledged the importance of involving the resident or her representative in care planning and confirmed that this did not occur. Review of facility policies showed that care conferences should be held with residents or their representatives and documented accordingly, but this was not followed in this case.
Failure to Provide Foley Catheter Privacy Bag Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a resident with a history of benign prostatic hyperplasia, bladder disease, and metabolic encephalopathy, who was totally dependent on staff for personal care and had an indwelling catheter, was observed without a privacy drainage bag covering the foley catheter. During an observation in the resident's room, the foley catheter drainage bag containing urine was exposed and not concealed with a privacy bag, contrary to the facility's standard practice and policy. Registered Nurse 1 confirmed that it is standard practice to use a privacy bag for all residents with a foley catheter to maintain dignity and prevent potential damage to the drainage bag. The Director of Nursing also stated that licensed nursing staff are responsible for applying privacy bags to promote resident dignity. The facility's policy on Resident Dignity and Personal Privacy requires care to be provided in a manner that respects and enhances each resident's dignity and right to personal privacy.
Failure to Timely Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to transmit a resident's Discharge Minimum Data Set (MDS) assessment to the Centers for Medicare and Medicaid Services (CMS) within 14 days after completion, as required. Review of the resident's records showed that the discharge MDS assessment, dated 3/9/2025, was not transmitted in a timely manner. The Minimum Data Set Nurse (MDSN) confirmed during interview and record review that the assessment had not been submitted to CMS, and acknowledged that all MDS assessments should be transmitted within 14 days from the Assessment Reference Date (ARD) or discharge date. The resident involved had a history of metabolic encephalopathy, epilepsy, and chronic obstructive pulmonary disease (COPD), and was noted to have severely impaired cognitive skills and total dependence on staff for several activities of daily living. The facility's policy required timely transmission of MDS assessments according to electronic medical record and RAI guidelines, but this process was not followed for the resident in question.
Failure to Complete PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
A deficiency occurred when the facility failed to submit a Pre-admission Screening and Resident Review (PASARR) for one of four sampled residents. The resident in question was admitted with diagnoses including schizophrenia, major depressive disorder, anxiety, and other persistent mood disorders. Review of the resident's Minimum Data Set (MDS) indicated severely impaired cognitive skills and a need for maximal assistance with activities of daily living. Despite these significant mental health diagnoses, there was no evidence that a Level 1 PASARR was completed upon admission as required. During an interview and record review, the DON confirmed that PASARR screenings are to be completed before or within 24 hours of admission, but acknowledged that the process was not followed for this resident. The DON also stated she had the capability to process PASARRs but had not been given access to do so. The facility's policy, dated December 2022, requires PASARR Level 1 screening for all potential skilled nursing facility residents, but this protocol was not adhered to in this case.
Failure to Develop Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop a baseline care plan for one of its residents within the required timeframe following admission. Specifically, a resident admitted with diagnoses including cerebral infarction, dysphagia, and liver cirrhosis did not have a baseline care plan created within 48 hours of admission, as required by facility policy. The resident's Minimum Data Assessment indicated a need for moderate assistance with oral hygiene, toileting hygiene, and personal hygiene, and the resident was able to express ideas and understand others. Interviews with facility staff, including the Social Service Director, MDS Nurse, and Director of Nursing, confirmed that the interdisciplinary team did not create the required baseline care plan for this resident. The facility's policy states that an interim plan of care should be developed within 48 hours of admission to address the resident's initial needs, using information from various sources such as referring facilities, physician orders, and assessments. The absence of this plan was acknowledged by staff during the survey.
Failure to Provide Ordered Low Air Loss Mattress for Pressure Ulcer Care
Penalty
Summary
A resident with a history of a Stage 4 pressure ulcer, major depressive disorder, bradycardia, and sepsis was readmitted to the facility and had a physician's order for a low air loss mattress to address their pressure ulcer. The resident's Minimum Data Set indicated moderately impaired cognitive skills and a need for partial assistance with activities of daily living. Despite the physician's order, the resident was observed lying on a regular mattress during a facility visit. The Director of Nursing confirmed that the resident did not have the ordered low air loss mattress and acknowledged that no such mattresses had been ordered for any resident in the past two months. Facility policy required the use of specialty mattresses for residents with pressure injuries or those at risk. The failure to provide the prescribed low air loss mattress constituted a deficiency in pressure ulcer care for this resident.
Failure to Complete Urology Referral for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a urology referral and appointment were completed for a resident who had been discharged from a general acute care hospital with orders for a urology evaluation, including urodynamics and cystogram, due to a history of urinary tract infection. The resident's admission record indicated diagnoses of benign prostatic hyperplasia, other specified diseases of the bladder, and metabolic encephalopathy. The Minimum Data Set assessment showed the resident was totally dependent on staff for oral hygiene, toileting, and personal hygiene, and had an indwelling catheter in place. Despite documentation in both the hospital discharge orders and facility progress notes indicating the need for a urology referral, the appointment was not scheduled. During interviews, the MDS nurse confirmed that the responsibility for scheduling the appointment rested with the licensed nursing staff and acknowledged that the referral should have been made but was not. The facility's policies required referrals to outside agencies to meet residents' needs and outlined interventions to prevent catheter-related urinary tract infections, but these were not followed in this case.
Failure to Complete Required Competency Checklists for CNA
Penalty
Summary
The facility failed to ensure that initial and annual competency checklists were completed for one of four sampled employees, specifically a Certified Nurse Assistant (CNA). A review of the CNA's personnel file revealed that there was no documentation of an initial competency checklist upon hire and no annual competency checklist for the following year, as required by facility policy. During an interview, the Director of Staff Development confirmed that these competency checklists were missing and acknowledged that they should have been completed according to the facility's procedures. The facility's policy states that nursing staff competency must be reviewed upon hire and annually during performance evaluations.
Failure to Limit PRN Antipsychotic Order and Respond to Pharmacist Recommendation
Penalty
Summary
The facility failed to respond to a consultant pharmacist's recommendation to limit a resident's PRN (as needed) order for Zyprexa, an antipsychotic medication, to a 14-day duration. The pharmacist made this recommendation on 3/23/25 after reviewing the resident's medication regimen, but the facility did not document any response or action taken regarding this recommendation. Review of the resident's Medication Administration Records (MAR) showed that the resident had active PRN orders for Zyprexa for periods exceeding 14 days, specifically from 3/6/25 to 3/30/25 (24 days) and from 3/31/25 to 4/16/25 (16 days). The resident had a history of bipolar disorder and schizophrenia and was assessed as having the capacity for medical decision-making. During an interview, the DON acknowledged that the facility did not limit the PRN Zyprexa order to 14 days as required and failed to respond to the pharmacist's recommendation. Facility policy requires that PRN antipsychotic orders be limited to 14 days and that any pharmacist recommendations be communicated to the physician with documentation of the rationale for medication changes. The facility's failure to follow these procedures resulted in the resident receiving PRN antipsychotic medication for longer than the policy allows, without documented physician evaluation or justification.
Incorrect Seroquel Dose Administered Due to Order and Label Discrepancy
Penalty
Summary
A Licensed Vocational Nurse (LVN) administered an incorrect dose of Seroquel to a resident diagnosed with schizophrenia. The resident was prescribed Seroquel 50 mg, with instructions to take one-half tablet by mouth every morning and at bedtime. However, during a medication administration observation, the LVN prepared and administered a full 50 mg tablet instead of the prescribed half tablet. The medication was provided in a bubble-pack containing only full tablets, and the pharmacy label instructed to give one full tablet twice daily, which did not match the physician's order. The LVN acknowledged the error, stating she failed to compare the medication label with the resident's current order and did not notice the discrepancy between the pharmacy label and the physician's order. The LVN also confirmed that the pharmacy had not received the updated order reflecting the decreased dose, resulting in the incorrect instructions on the medication packaging. The facility's policy requires staff to compare the medication and dosage on the Medication Administration Record (MAR) with the medication label and to verify with the physician's order if there are discrepancies, which was not followed in this instance.
Failure to Complete Ordered Levetiracetam Level for Resident with Epilepsy
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of epilepsy received timely laboratory monitoring as ordered by the physician. Specifically, the physician had ordered a Levetiracetam blood level to be completed on the next lab day and every three months thereafter. Review of the resident's records showed that this test was not completed as ordered. The care plan for the resident indicated that laboratory results were to be monitored and any subtherapeutic or toxic results reported to the physician, but there was no evidence that the required Levetiracetam level was obtained. During an interview and record review with an LVN, it was confirmed that the Levetiracetam blood test had not been performed. The LVN acknowledged the importance of the test in ensuring the medication dosage was appropriate and stated that the physician relied on these results to determine if adjustments were needed. The resident's medical history included hypertension, diabetes mellitus, and epilepsy, and the resident was assessed as needing moderate assistance with activities of daily living.
Incomplete Medical Record Documentation and Missing X-ray Results
Penalty
Summary
The facility failed to ensure that the medical records for a resident were complete and that the x-ray results were accessible and properly filed. Specifically, a physician ordered a stat x-ray of the resident's left leg and foot to evaluate pain and swelling, but the results were not available in the resident's medical record. There was no documentation of communication with the physician regarding the x-ray results, nor any evidence of follow-up with the x-ray provider. During a review, a nurse confirmed that the medical records were incomplete and that if documentation was missing, it was considered not to have occurred. The Director of Nursing stated that she had received the x-ray results and given them to a licensed nurse, but could not explain why the results were not accessible in the medical record and could not provide documentation that the results were reported to the physician. The facility's policies require that records be complete, accessible, and filed in a manner that allows for easy retrieval, and that staff document and report results of diagnostic tests to the physician. The failure to maintain complete and accessible records was observed during interviews and record reviews.
Failure to Disinfect Shared Blood Pressure Cuff Between Uses
Penalty
Summary
Staff failed to disinfect a shared blood pressure cuff before and after use during medication administration for two residents. During medication administration, a Licensed Vocational Nurse (LVN) was observed taking the blood pressure of one resident using an automatic blood pressure machine with a Velcro-style cuff without disinfecting it prior to use. After use, the LVN placed the machine and cuff back into its case and returned it to the medication cart without cleaning or disinfecting it. Shortly after, the same LVN used the same blood pressure machine and cuff to take another resident's blood pressure, again without disinfecting the cuff before or after use. The LVN acknowledged during an interview that she did not clean or disinfect the blood pressure cuff before or after taking blood pressures for both residents, despite being required to do so by facility policy. The facility's policy, revised in August 2017, states that all resident-contact surfaces, including blood pressure cuffs and tubing, must be cleaned and disinfected after each use.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation to the California Department of Public Health (CDPH) within the required timeframe for two of three sampled residents. Resident 118, who had a history of bipolar disorder, anxiety, polyosteoarthritis, and myalgia, was found on the floor in his room and stated that his roommate had tripped him. Resident 59, who had diagnoses including abnormalities of gait and mobility, psychosis, muscle wasting, and lack of coordination, denied the allegation. Both residents were assessed as having moderately impaired cognitive skills and required partial assistance with activities of daily living. The incident occurred on 6/8/2025, but the facility did not report the allegation to CDPH until 6/10/2025. Interviews with the Director of Nursing (DON) and Assistant Administrator revealed that they were not informed of the incident on the day it occurred. The DON and Assistant Administrator both acknowledged that the facility's policy required reporting allegations of abuse within two hours, especially if the incident involved abuse or resulted in serious bodily injury. The delay in reporting resulted in a delay in CDPH's investigation and placed other residents at risk for further abuse.
Insufficient Living Space Provided in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that residents in multiple rooms, specifically rooms 101, 102, 103, 104, 105, 106, 107, 109, 110, 111, 112, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 126, and 127, had at least 80 square feet of living space per resident as required. Observations showed that these rooms contained three beds each, and a review of the Client Accommodation Analysis confirmed that the floor space in these rooms was 215 square feet, which is insufficient for three residents. The facility submitted a Room Variance Waiver request for these rooms, stating that the configuration allows for wheelchair accessibility and does not hinder care. However, during an interview, the Assistant Administrator acknowledged that the smaller rooms could potentially make it difficult for nursing staff to provide care.
Failure to Ensure Safe and Informed Discharge for High-Risk Resident
Penalty
Summary
A resident with diagnoses including schizophrenia, major depressive disorder, and diabetes mellitus was discharged from the facility without their knowledge, request, or consent, and against medical advice. The resident had a documented history of elopement risk, with assessments indicating a significant actual risk for wandering or leaving the facility. The care plan and risk assessments reflected these concerns, and physician orders permitted the resident to leave the facility only under specific conditions, such as being out on pass for a limited time. On the day in question, the resident left the facility after stating an intention to go to the post office, but did not complete the required sign-out process, and the log was left incomplete. Staff interviews revealed that the resident was not properly signed out, and that staff were aware of the resident's behavioral challenges, including agitation and aggression. Following the resident's departure, the facility was unable to confirm the resident's whereabouts or safety, and attempts to contact the resident's emergency contact were unsuccessful. The facility subsequently classified the resident as having left against medical advice and processed a discharge without confirmation of the resident's location or well-being. Facility policy required all residents leaving the facility to be signed out, a step that was not completed in this case. The deficiency was identified due to the facility's failure to ensure a safe and informed discharge process, particularly for a resident with known elopement risk and behavioral health concerns.
Failure to Provide Clean Bed Linens for Two Residents
Penalty
Summary
The facility failed to provide a clean and homelike environment for two residents by not ensuring that their bed linens were changed daily or when soiled. Observations revealed that one resident's bed linen was covered with black and brown spots, and the resident reported that the linens had not been changed for a long time and were not changed daily. A Certified Nurse Assistant (CNA) confirmed the linen was dirty and was unsure when it was last changed, acknowledging that it was not acceptable for residents to lay on soiled linen. The resident's medical history included schizophrenia, anxiety disorder, and unspecified psychosis, and the resident required partial to moderate assistance with activities of daily living (ADLs). Another resident, with diagnoses including chronic obstructive pulmonary disease (COPD), muscle wasting and atrophy, and congestive heart failure (CHF), also had dirty bed linen with dry black and red spots observed. This resident required substantial to maximal assistance with ADLs. A CNA confirmed the linen was dirty and stated that it was facility policy to change linens daily. The Director of Nursing (DON) stated that linens should be changed daily for infection control, prevention of skin breakdown, and resident dignity, and that it was the facility's responsibility to maintain a homelike environment. Facility policies and job descriptions reviewed also indicated the expectation for staff to provide clean linens and maintain cleanliness.
Failure to Provide Adequate Assistance During Resident Transfer
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident by not ensuring that a Certified Nursing Assistant (CNA) provided a two-person physical assist when using a Hoyer Lift to transfer the resident from the bed to a Geri-chair. This resulted in the resident falling and sustaining an acute fracture of the right femoral neck. The resident was subsequently transferred to a general acute care hospital for evaluation and treatment five days after the fall. The resident, who had diagnoses including paraplegia, muscle wasting and atrophy, and major depressive disorder, was totally dependent on staff for transfers and activities of daily living, requiring a two-person assist as per their care plan. During the incident, CNA 1 attempted to transfer the resident alone using the Hoyer Lift, which malfunctioned due to a dead battery. Despite this, CNA 1 continued the transfer without assistance, leading to the resident falling to the floor on their knees. Interviews with staff revealed that the facility's policy required two staff members to assist with transfers using a Hoyer Lift for safety reasons. The CNA involved had not previously transferred the resident and did not seek help from other staff members. The facility's policies and procedures emphasized the importance of resident safety and the use of appropriate techniques and devices for lifting and transferring residents, which were not followed in this instance.
Failure to Report Resident Fall Resulting in Hip Fracture
Penalty
Summary
The facility failed to report a fall incident that resulted in a hip fracture to the California Department of Public Health (CDPH). The incident involved a resident with paraplegia, muscle wasting, atrophy, and major depressive disorder, who was totally dependent on staff for transfers and activities of daily living. The resident reported falling to the floor and hitting his knees during a transfer from bed to chair, assisted by a CNA using a Hoyer Lift. The lift's battery died, and during a second attempt to transfer, the resident fell. The resident was later transferred to a general acute care hospital (GACH) where an X-ray confirmed an acute fracture through the right femoral neck. Despite being informed by the GACH of the resident's fracture, the facility did not report the incident to CDPH. The Director of Nursing and the Assistant Administrator both stated that the fall was witnessed by the CNA, and they assumed the GACH would report the injury to CDPH. The facility's policy and procedure on incident reporting indicated that events with undesirable outcomes should be reported to federal and state agencies, but this was not followed in this case.
Flies in Resident Rooms Compromise Homelike Environment
Penalty
Summary
The facility failed to provide a safe and homelike environment for four residents, as flies were observed in their rooms. Resident 1, who has a history of psychosis, schizophrenia, and anxiety disorder, was found with flies on his clothing, bed, and belongings, which made him feel unhygienic and dehumanized. Licensed Vocational Nurse 1 confirmed the presence of flies and acknowledged the potential for disease and infection spread. Resident 2, with a history of diabetic polyneuropathy, morbid obesity, and cellulitis, also experienced the presence of flies in his room. He reported feeling annoyed and sad due to the flies, which had been present since the previous Friday. Certified Nurse Assistant 2 and Resident 2 both confirmed the presence of multiple flies, and CNA 1 had reported the issue to an LVN on the same day. Residents 3 and 4, both with histories of mental health disorders, also experienced flies in their rooms. Resident 3 expressed annoyance and discomfort, while Resident 4 reported the flies had been present since the previous Friday. The Maintenance Director and the Director of Nursing were informed of the issue, but there was a delay in addressing the problem. The facility's policies on maintaining a homelike environment and pest control were not effectively implemented, leading to the deficiency.
Failure to Investigate Missing Personal Belongings
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding residents' personal property when a grievance was not filed, and an investigation was not conducted after a resident reported missing belongings. The resident, who had a history of major depressive disorder and anxiety, expressed sadness over the facility's inaction. Despite the resident's ability to make medical decisions and report feeling down nearly every day, the facility did not provide an opportunity for the resident to file a grievance or investigate the missing items. Interviews and record reviews revealed that the Social Services Director (SSD) was informed of the missing belongings but did not document the allegation or conduct a formal investigation. The Director of Nursing (DON) confirmed that the facility's policy required all reported lost properties to be investigated and documented, which was not done in this case. The lack of documentation and failure to follow the grievance process resulted in a violation of the resident's rights.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was plugged in and within reach, as required by the facility's policy and procedure titled 'Answering Call Lights.' During an observation, it was noted that the call light socket in the resident's room was empty, and the call light was not visible on the bed or floor. This was confirmed during an interview with the resident, who stated that the call light had been missing. The Licensed Vocational Nurse (LVN) present in the room did not notice or address the missing call light. The resident involved had a history of major depressive disorder and anxiety, with mild cognitive impairment but the ability to make medical decisions. The facility's policy, reviewed with LVN 2, clearly stated that staff must ensure call lights are plugged in and within reach of residents at all times. The Maintenance Director and a Certified Nursing Assistant (CNA) both acknowledged the importance of call lights for alerting staff to residents' needs and the potential consequences if they are not available. Despite this, the call light for this resident was not monitored or corrected by staff, leading to the deficiency.
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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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