Inglewood Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Inglewood, California.
- Location
- 100 S. Hillcrest Blvd, Inglewood, California 90301
- CMS Provider Number
- 055526
- Inspections on file
- 61
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 29 (1 serious)
Citation history
Health deficiencies cited at Inglewood Health Care Center during CMS and state inspections, most recent first.
A resident with ESRD, COPD, severe cognitive impairment, and dependence on hemodialysis had physician orders for dialysis three times weekly with a set transportation pick-up and return time. On one treatment day, the resident was not picked up at the scheduled time, and progress notes showed the resident received only a partial dialysis session. The contracted transportation company reported that no transport had been scheduled initially and that they were called later in the morning, leading to a delayed pick-up. The SSD, who managed transportation based on standing dialysis orders, stated she did not track the contracted number of pick-up days or remaining trips, which resulted in the missed scheduled transport and shortened dialysis treatment, contrary to facility policies on transporting residents and providing appropriate hemodialysis care.
Two residents did not receive medications in accordance with professional standards when scheduled doses were repeatedly administered late and one resident’s oral medications were left at the bedside without verification of ingestion. One resident with DM, acute kidney failure, and encephalopathy had multiple 9 a.m. and TID medications, including antihypertensives, antiplatelets, anxiolytics, anticonvulsants, and antipsychotics, documented as late over several days, and a nurse admitted leaving the 9 a.m. medications at the bedside, charting them as given on time even though they were taken hours later. Another resident with toxic encephalopathy, HTN, and a GT had aspirin and a stool softener ordered via GT at 9 a.m., but an LVN was observed administering these medications more than two hours late while acknowledging the delay. Facility policy required medications to be given accurately, safely, and timely, and to verify that medications were actually taken.
A resident with PVD, DM, obesity, and HTN, who was cognitively able to make decisions and required supervision or setup assistance for mobility and ADLs, did not have a discharge care plan developed. An MDS nurse reported she could not locate a discharge care plan and stated that Social Services was responsible for discharge planning. The SSD confirmed that no discharge care plan existed for this resident, despite department responsibility for creating such plans. Facility policy required a comprehensive care plan with goals, measurable objectives, and timetables to address medical, nursing, mental, and psychosocial needs, including potential community discharge, but this was not implemented for this resident.
The facility failed to timely report multiple resident-to-resident abuse incidents to CDPH as required by federal regulations, AFL 24-09, and its Abuse Prevention Program policy. One resident with pneumonia, a cardiac pacemaker, and a right hip fracture, who was cognitively able to communicate, reported being repeatedly hit with a purse and later scratched on the face by another resident, resulting in observable facial wounds. Another resident with schizophrenia, dementia, and hypertension was slapped on the shoulder in a hallway by a resident with vascular dementia, metabolic encephalopathy, and a UTI, who was also documented as hitting residents and staff on several occasions. These events were recorded in SBARs, progress notes, and interviews, but the RN and the administrator acknowledged that the facial scratch incident and all incidents involving the resident with dementia were not reported to CDPH within the required 2-hour or 24-hour timeframes, even though they were reported to the ombudsman and police, leading to delayed state investigation and the risk of further abuse and serious harm.
The facility failed to report an alleged verbal abuse incident to the State agency as required. A resident with morbid obesity, HTN, and intact decision-making capacity had a verbal altercation with the Social Services Director after the director instructed the resident’s family member to wear a mask and told the resident not to worry about an outbreak because the resident was leaving. The resident called the director a derogatory name, the director raised her voice in response, and an RN intervened. The resident later described the director’s behavior as threatening and unprofessional. An RN reported the incident to the ADM, but the ADM did not notify the State agency, despite facility policy and CMS requirements to report all abuse allegations within specified timeframes.
A resident with morbid obesity, HTN, and intact decision-making capacity had a documented verbal altercation with the SSD after the SSD instructed the resident’s family member to wear a mask and declined to disclose details about an outbreak. The resident became upset, yelled at the SSD, and called her a derogatory name; the SSD returned to the room and questioned the resident about the insult. The resident later reported feeling threatened, describing the SSD as yelling, waving her arms, and attempting to re-enter the room. Despite facility policies and federal requirements mandating investigation of all abuse allegations, the ADM acknowledged that no abuse investigation was conducted and that the matter was instead treated as a grievance, with no evidence of a formal investigation or required reporting.
A resident with morbid obesity, hypertension, and intact decision-making capacity became upset after the SSD entered the room to instruct a visiting family member to wear a mask during an Influenza A outbreak and then refused to disclose the type of outbreak, reportedly adding that the resident was leaving anyway. As the SSD exited, the resident called her a derogatory name, and the SSD turned back, re-entered or attempted to re-enter the room, raised her voice, and questioned the resident about the insult, requiring an RN to step between them. The resident later reported feeling threatened and afraid of the SSD, and another resident corroborated that the SSD returned and yelled at the first resident, leading surveyors to find that the SSD failed to meet professional standards of quality in her interaction.
A resident with cerebral infarction, DM, and dementia, who had decision-making capacity, had a documented care plan and widely known preference to refuse ADL care from male CNAs and be assisted only by female CNAs. Despite this, nursing assignments for a night shift placed a male CNA in charge of the resident’s ADL care, contrary to the resident’s expressed wishes and the facility’s dignity policy, which commits to honoring resident choices, preferences, values, and beliefs.
The facility failed to report an influenza A outbreak to the state health department within the required 24-hour timeframe after two residents, both documented as capable of making medical decisions (one cognitively intact and one with moderate cognitive impairment), had positive influenza antigen tests on the same day. The Infection Preventionist acknowledged that, under the county outbreak toolkit, two or more lab-confirmed influenza cases within 72 hours constitute an outbreak that must be reported, and the facility’s Unusual Occurrence Reporting policy and the IP job description required timely reporting of communicable disease outbreaks to appropriate agencies. The Administrator confirmed that the outbreak was not reported within 24 hours, resulting in delayed investigation by the state agency.
A resident with heart failure, stage four CKD, and COPD, who was cognitively intact and self-responsible, tested positive for Influenza A and exhibited fever, vomiting, and cough. An NP gave a verbal order for Tamiflu 75 mg twice daily for five days, but the receiving nurse failed to transcribe the order onto a telephone order form, did not enter it on the MAR, and did not notify the pharmacy, contrary to facility policy. As a result, the Tamiflu order was not reflected in the physician orders or MAR, and the resident missed two doses of the antiviral medication.
A resident with dementia, metabolic encephalopathy, and osteoporosis, who was dependent on staff for ADLs, was kicked in the right shin by a CNA while the CNA was in the room feeding the resident’s roommate. An RN overheard the CNA speaking to the resident, then directly observed the kick, removed the resident from the room, and the resident indicated she had been hit and was in pain. Documentation later that day noted discoloration to the resident’s right leg. This incident occurred despite a facility policy prohibiting abuse, neglect, and exploitation and guaranteeing residents the right to be free from mistreatment.
A resident with dementia, severe cognitive impairment, generalized weakness, and a history of multiple falls was assessed as high risk for elopement and wandering, with care plans calling for a wander guard, bed and wheelchair alarms, visible placement, checking whereabouts, and incremental monitoring. These interventions were described by nursing staff and the DON as vague, were not clearly defined, and were not consistently implemented or documented, including failure to place the resident in a visible area and to carry out incremental monitoring. While the receptionist was on break, an RN briefly assumed responsibility for monitoring the lobby and exit door but left the area to go to the medication room without assigning another staff member, leaving the lobby and exit unsupervised. Shortly thereafter, the wander guard alarm sounded; staff found the resident outside, falling on the sidewalk, with no wheelchair alarm heard, and the resident sustained a closed head injury, intracranial hemorrhage, and fractures of two fingers, which staff and the DON attributed to lack of supervision and failure to follow the fall and wandering care plan.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident with moderately impaired cognition, who preferred independent activities such as watching TV, was unable to watch television in her room due to one TV displaying static and another not being plugged in. Both the resident and her family reported issues with the TV, and staff confirmed the lack of a functioning television, contrary to facility policies supporting person-centered care.
A resident with severe cognitive impairment and a history of refusing care was subjected to a blood draw despite expressing refusal, resulting in pain and bruising. Staff did not follow physician orders or facility protocol to contact the family when the resident refused, and proceeded with the procedure against the resident's wishes.
A resident with moderate cognitive impairment and a history of intracerebral hemorrhage and respiratory failure requested partial dentures, but did not receive follow-up dental services or the requested dentures. Despite documentation of the request and facility policies assigning responsibility to social services for dental referrals and follow-up, no further action was taken after the initial dental evaluation.
A resident with severe cognitive impairment and total dependence on staff for care was not changed in a timely manner after episodes of incontinence, as required by their care plan. Family reported the resident was sometimes left wet for extended periods, and staff interviews confirmed the risks associated with such lapses, including skin breakdown and infection.
A resident with dementia, osteoarthritis, and moderate cognitive impairment experienced ongoing pain that was not adequately addressed, as staff failed to complete a pain management evaluation or administer as-needed pain medication despite repeated reports of pain and existing physician orders. Interviews confirmed that a referral to pain management was not completed, and the facility's policy for pain evaluation and referral was not followed.
A resident who was severely cognitively impaired and fully dependent on staff was found to have no soap dispenser in their bathroom, with an un-labeled cup of liquid left on the sink instead. Staff failed to report or address the missing dispenser, and maintenance was unaware of the issue, resulting in a lapse in infection prevention and control practices as required by facility policy.
A resident with recent digestive system surgery and a Jackson Pratt drain was unable to attend a scheduled follow-up appointment with a surgeon due to the facility's failure to arrange transportation, despite physician orders and internal notifications. Documentation showed no evidence of transportation arrangements, and the responsible staff member could not recall or provide proof of arranging the required service.
A facility failed to implement proper infection control practices during wound care for three residents. An LVN was observed not adhering to hand hygiene protocols, such as washing hands between glove changes and removing PPE before leaving the work area. These actions were contrary to the facility's policies, potentially leading to cross-contamination and infection.
A resident with severe cognitive impairment and a no CPR order had a low blood pressure reading, leading to the withholding of medication. The resident's baseline blood pressure was typically low after dialysis. A nurse admitted she could have rechecked the blood pressure and informed the physician. The DON emphasized the importance of monitoring low blood pressure and informing the physician if it remained low.
A resident with cognitive and physical impairments, identified as high risk for falls, was left unattended with a raised bed during wound care by an LVN and CNA. This action was against the facility's policy, which prioritizes resident safety and supervision to prevent accidents.
The facility failed to conduct annual competency assessments for a RN and four CNAs, as required by their policy. The DSD acknowledged the absence of these assessments, which are crucial for validating staff ability to meet resident health and safety needs. The Administrator emphasized the importance of these assessments for compliance with regulations.
The facility failed to meet the nutritional needs and preferences of its residents. A resident who was a vegetarian was served meals containing meat, and incorrect portion sizes were served to residents on mechanical soft and pureed diets. Staff did not adhere to the facility's policies on food preferences and portion control.
The facility failed to properly store and label food items, with unlabeled frozen water and undated opened food found in the refrigerator. An internal fan with black substances was blowing over uncovered produce, risking cross-contamination. Interviews with the DDS and RD confirmed these issues, which were against the facility's policies for food storage and maintenance.
The facility failed to update its Facility Assessment to reflect the accurate resident census, with a discrepancy between the recorded average daily census and the actual number of residents. The Administrator acknowledged the mismatch and the potential risk of not providing quality care due to incorrect documentation. CMS guidance requires regular updates to the Facility Assessment to ensure accurate evaluation of resident needs.
A facility failed to implement its antibiotic stewardship program by not monitoring a resident's antibiotic use for a UTI. The resident, with a history of UTI, sepsis, and diabetes, was readmitted with a prescription for Bactrim DS. The IPN did not complete the required surveillance form, and no lab specimens were drawn post-hospital discharge, contrary to facility policy. The DON noted this could lead to unnecessary antibiotic use and potential harm.
A resident's family filed a grievance about a CNA's loud and rude behavior, but the CNA continued to be assigned to the resident for three days. The resident, who was fully dependent on staff, experienced a lack of dignity and respect. Despite acknowledgment of the grievance, the intervention to remove the CNA was not implemented.
A resident with severe cognitive impairment was not informed when her missing EBT card was found by the Activities Director, causing prolonged distress. The card, valued at $190, was reported missing by a CNA, but the Activities Director did not notify staff or the resident upon finding it, delaying resolution.
A resident with severe cognitive impairment was not offered the opportunity to file a grievance for a missing EBT card, valued at $190, as required by the facility's policy. The Social Services Director and DON were unaware of the issue, and the grievance process was not followed, potentially causing distress to the resident.
The facility failed to accurately complete the MDS for two residents, leading to incorrect data transmission to CMS. One resident's MDS did not acknowledge a schizophrenia diagnosis, while another's MDS was inaccurately coded for schizoaffective disorder. The MDS Nurse confirmed these inaccuracies, which could impact the quality of care. The facility's policy requires certification of MDS accuracy, which was not followed.
The facility failed to resubmit the PASRR for two residents with mental illness, potentially impacting their mental health care. One resident with schizophrenia and dementia did not have a resubmitted PASRR, while another with schizoaffective disorder had an inaccurately completed PASRR level 1 screening, missing the need for a level 11 evaluation. The facility's policy required staff to review PASRRs and determine follow-ups, which was not followed.
The facility failed to create person-centered care plans for two residents, one requiring supervision for smoking and another following grievances about staff behavior. Despite assessments indicating the need for specific care plans, none were documented, potentially affecting the delivery of necessary care.
A resident with visual impairment and fluctuating decision-making capacity experienced frustration due to the facility's failure to clean and provide dentures daily. Despite needing substantial assistance, the resident reported that staff did not clean the dentures or place them within reach before meals. Observations confirmed the dentures were not offered during meals, and a CNA admitted they were not accessible. The facility's policies on denture care were not followed, leading to the resident's inability to use the dentures effectively.
A resident with impaired vision and cognitive issues did not receive a timely ophthalmology appointment for cataracts and glaucoma evaluation. The Social Service Director was unaware of the need for the referral, and there was no documentation or follow-up, contrary to the facility's policies.
A resident at high risk for skin breakdown had their low air loss (LAL) mattress incorrectly set at 400 pounds instead of their actual weight of 101 pounds. This error was identified by an LVN, who confirmed the potential risk for pressure ulcers. The resident's medical history included conditions like dementia and COPD, increasing their vulnerability. The facility's policy emphasized the importance of correct mattress settings for pressure relief.
A resident with blindness and fluctuating decision-making capacity was not provided with the correct diet texture, as they did not wear dentures. Despite being on a low sodium regular diet, the facility did not adjust the food texture, making it difficult for the resident to chew, particularly meat. Interviews with the RD and MDS Nurse highlighted the need for a diet texture adjustment to prevent potential weight loss and ensure proper nutrition.
A resident with PTSD and depression did not receive trauma-informed care as required by facility policy. Despite the resident's traumatic experience of losing his wife, staff failed to provide necessary psychosocial support or offer group therapy, leading to a deficiency in care.
A facility failed to follow physician orders for a resident's oxygen settings, setting the concentrator at three liters per minute instead of the prescribed two liters. The resident, with severe cognitive impairment and multiple health issues, was at risk due to this oversight. Staff acknowledged the error and the importance of adhering to physician orders to prevent potential harm.
A resident grieving the loss of his wife did not receive necessary emotional support and social services, including group therapy and psychological referral, despite expressing ongoing grief and having a care plan in place. The Social Service Director admitted to the lack of interventions, which contradicted the facility's policies on providing appropriate treatment for mental and psychosocial difficulties.
A facility failed to act on a pharmacy consultant's recommendation for a trial reduction of a psychotropic medication for a resident. The consultant pharmacist suggested reducing Seroquel, prescribed for paranoia, but the facility did not inform the resident's physician, and no action was taken. The resident had intact cognitive skills and required setup assistance. The Director of Nursing acknowledged the failure to follow the facility's policy for Medication Regimen Review and Reporting.
A facility failed to label an opened multi-dose tuberculin vial with an expiration date in the medication storage room. During an observation, a nurse found the vial in the refrigerator with a date but no expiration date, acknowledging the potential for medication errors. The facility's policy required refrigerated medications to be labeled, but this was not followed.
A facility failed to date and label an oxygen humidifier for a resident with severe cognitive impairment and multiple health conditions, increasing the risk of respiratory infection. The LVN and DON confirmed that the humidifier should be changed weekly and labeled, but this was not done, violating the facility's infection control policy.
Two residents at risk for falls had care plans that were not individualized to specify the level of staff assistance needed for safe transfer and mobility. Despite being identified as high risk for falls, the care plans did not reflect the assistance levels indicated by physical therapy assessments. Interviews with the RN and DON confirmed that care plans should be individualized, and the lack of specificity could increase fall risks. Facility policies emphasized the need for resident-centered fall prevention plans, which were not met in these cases.
A resident, assessed as needing partial/moderate assistance due to conditions like radiculopathy and spinal stenosis, fell in the bathroom when a CNA failed to provide necessary support. Despite being at high risk for falls, the CNA did not maintain close proximity or physical support, contrary to the facility's safety and fall management policies.
A resident in an LTC facility was physically abused by another resident due to the facility's failure to follow care plans and physician's orders for monitoring aggressive behaviors. The aggressive resident had a history of altercations and was not adequately supervised or separated from the victim, leading to an incident where the victim sustained a hematoma. The facility did not notify the physician or implement effective interventions despite multiple episodes of aggression.
A resident with dementia and other medical conditions left the facility unsupervised due to a failure in following elopement and safety supervision policies. Despite being assessed as at risk for wandering, the resident's wander guard alarm did not sound, and staff did not visually confirm the resident's presence. Interviews revealed lapses in supervision and alarm system functionality, leading to the resident's unsupervised departure.
A resident with acute kidney failure, an automatic cardiac defibrillator, and hypertension frequently left the facility without a required physician order, compromising their safety. The facility's policies mandate a physician order for residents to leave, but this was not followed, as confirmed by the DON.
Failure to Arrange Timely Transportation Resulting in Incomplete Dialysis Treatment
Penalty
Summary
The facility failed to ensure timely transportation for a resident with ESRD who required hemodialysis three times weekly, resulting in the resident arriving late and receiving only a partial dialysis treatment. The resident had diagnoses including COPD, ESRD, and dependence on renal dialysis, and had fluctuating capacity to understand and make decisions, with an MDS indicating severely impaired cognitive skills and a need for substantial/maximal assistance with activities of daily living. Physician orders specified dialysis on Tuesdays, Thursdays, and Saturdays with a scheduled transportation pick-up time of 7:15 a.m. and return at 12 p.m., and nursing staff confirmed there had been no changes to these transportation orders. On the date of the incident, progress notes documented that the resident was not picked up at the scheduled standing pick-up time for dialysis and subsequently received an incomplete dialysis cycle of only two and a half hours. The contracted transportation company reported that no transportation had initially been scheduled for that day and that they only received a call from the facility later that morning, resulting in a delayed pick-up at 10 a.m. The transportation company also stated that the resident’s transportation services had been reactivated to start on a later date. The Social Services Director, who was responsible for managing residents’ transportation based on standing dialysis orders provided by licensed nurses, acknowledged that she did not track the contracted number of pick-up days or remaining trips, which led to the resident not being transported on time and receiving only partial dialysis treatment. Facility policies stated that transportation to appointments would be facilitated by Nursing or Social Services and that the facility would provide safe, accurate, appropriate hemodialysis-related care and coordination.
Failure to Administer and Monitor Medications per Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in a timely manner and in accordance with physician orders, and that oral medications were not left at the bedside without verification of ingestion. For one resident with type 2 DM, acute kidney failure, and encephalopathy, the admission record showed she had clear speech, could express ideas and wants, and required partial/moderate assistance with toileting, bathing, and personal hygiene. A disciplinary action record dated 4/20/2026 documented that a charge nurse left this resident’s 9 a.m. medications at the bedside without confirming or observing that they were taken; the medications were later found by a family member. The disciplinary notice stated that leaving medications at the bedside threatened the resident’s safety, enabled hoarding of medications, and was viewed as negligence and failure to follow standards of care. Review of this resident’s Medication Administration History for April 2026 showed multiple instances of late administration of scheduled medications. Amlodipine 10 mg scheduled at 9 a.m. was charted late on several dates, as were aspirin 81 mg at 9 a.m., buspirone 5 mg at 9 a.m. and 5 p.m., gabapentin 100 mg three times daily at 9 a.m., 1 p.m., and 5 p.m., and quetiapine 25 mg three times daily at 9 a.m., 1 p.m., and 5 p.m. During an interview, the charge nurse stated that on 4/20/2026 at 9 a.m. he left the resident’s medications at the bedside at her request, documented them as given on time, but acknowledged the medications were actually taken later, between 11 a.m. and 12 noon. He stated that leaving medications at the bedside and failing to administer and observe the resident swallowing them could result in another resident taking the medications, the medications being lost, and adverse reactions. For a second resident with toxic encephalopathy, hypertension, and gastrostomy status, the MDS indicated clear speech with some difficulty communicating but able if prompted, and that the resident required setup or clean-up assistance with toileting, personal hygiene, and eating. The physician order report directed that aspirin 81 mg and docusate sodium 100 mg be administered via GT once daily at 9 a.m., with medications to be crushed as needed. On observation and concurrent interview at the bedside, an LVN was seen administering the resident’s 9 a.m. aspirin and docusate via GT at 11:40 a.m. and stated the medications were late because he was assisting other residents. The Medication Administration History confirmed that on that date both the aspirin and docusate scheduled for 9 a.m. were charted late. The facility’s undated policy on oral medication administration stated that oral medications should be administered in an accurate, safe, and timely manner and that staff should verify that medications were actually taken.
Failure to Develop Discharge Care Plan for A Resident
Penalty
Summary
Surveyors identified a failure to develop a discharge care plan for one of three sampled residents. The resident was admitted with diagnoses including peripheral vascular disease, diabetes mellitus, obesity, and hypertension. A History and Physical dated 7/31/2025 documented that the resident had the capacity to understand and make decisions. A Minimum Data Set (MDS) assessment dated 2/4/2026 showed the resident was able to understand and be understood by others and required supervision or touching assistance for walking, and setup or clean-up assistance for showering/bathing, sit-to-stand, and transfers. Despite these identified needs and the resident’s potential for community discharge, there was no discharge care plan developed for this resident. During an interview and concurrent record review on 4/13/2026, the MDS nurse reported she could not locate a discharge care plan for the resident and stated that Social Services was responsible for creating discharge plans. She explained that care plans serve as a guide for safe resident discharge, including interventions such as education for safe medication administration at home and follow-up with home health and physician appointments, and that they help ensure a continuum of care. In a subsequent interview and record review on 4/14/2026, the Social Services Director confirmed there was no discharge care plan for the resident and acknowledged that the Social Services Department was responsible for creating discharge care plans for all residents. The facility’s undated Comprehensive Plan of Care policy indicated that each resident would have a comprehensive care plan with goals, measurable objectives, and timetables to meet medical, nursing, mental, and psychosocial needs, including potential community discharge, which was not followed in this case.
Failure to Timely Report Resident-to-Resident Abuse Incidents to CDPH
Penalty
Summary
The deficiency involves the facility’s failure to timely report multiple resident-to-resident abuse incidents to the California Department of Public Health (CDPH) as required by federal regulations, state guidance (AFL 24-09), and the facility’s Abuse Prevention Program policy. Surveyors identified that three sampled residents were involved in several abuse incidents that were documented in clinical records but not reported to CDPH within the mandated timeframes. The facility’s own policy stated that administration would report any allegations of abuse within timeframes required by federal requirements, and AFL 24-09 required written notice to the appropriate state agency for incidents resulting in physical harm, but these requirements were not followed. Resident 1, who had diagnoses including pneumonia, presence of a cardiac pacemaker, and a displaced intertrochanteric fracture of the right femur, was cognitively able to express ideas and understand according to the MDS dated 2/17/2026. Record review showed multiple incidents involving Resident 1 and other residents. On 3/14/2026, an SBAR documented that Resident 1 reported being hit by Resident 3 swinging a purse at her. On 3/25/2026, another SBAR indicated Resident 1 was hit by Resident 3, and an interview record documented Resident 1 stating that Resident 3 hit her on the back with a purse while she was in her wheelchair. On 3/31/2026, an SBAR documented that Resident 2 scratched Resident 1’s face while entering or exiting a room, resulting in a wound on the chin measuring 1 x 0.2 (unit not indicated) and an upper lip wound measuring 0.2 (unit not indicated) with minimal blood noted. An interview record and subsequent observation confirmed Resident 1’s report that another resident with long fingernails scratched her face, and a red scratch on the chin was observed. Resident 2, with diagnoses including schizophrenia, unspecified dementia, and hypertension, was also documented as cognitively able to express ideas and understand per the MDS. On 3/10/2026, an SBAR and progress notes documented that Resident 3, in a wheelchair, passed by Resident 2 while she was sitting in a chair in the hallway and slapped her on the right shoulder. On 3/31/2026, an SBAR documented that Resident 2 exhibited aggressive behavior and scratched another resident while exiting the activity room. Resident 3, who had vascular dementia, metabolic encephalopathy, and a UTI, was documented in multiple SBARs as hitting residents and staff on 3/10/2026, swinging a purse at Resident 1 on 3/14/2026, and hitting Resident 1 on 3/25/2026, with staff witnessing at least one of these events. Despite these documented incidents of resident-to-resident physical contact and injury, interviews with the RN and the Administrator confirmed that the incident on 3/31/2026 involving Resident 1’s facial scratch and all of Resident 3’s incidents on 3/10/2026, 3/14/2026, and 3/25/2026 were not reported to CDPH within the required two-hour or 24-hour timeframes. During interviews, RN 1 acknowledged that the 3/31/2026 incident in which Resident 2 scratched Resident 1’s face and caused an injury was not reported to CDPH and stated it should have been reported within two hours. The Administrator stated that the 3/31/2026 incident was reported to the Ombudsman and police but not to CDPH within two hours, and further stated that none of Resident 3’s incidents were reported to CDPH because Resident 3 had dementia and the facility believed AFL 24-09 only required reporting to the Ombudsman and police in such cases. Review of AFL 24-09, however, showed that for incidents resulting in physical harm, facilities are required to notify local law enforcement immediately but not later than two hours and to provide written notice of the incident to the appropriate state agency. Review of the State Operations Manual, Appendix PP, F600 and F609, confirmed that facilities must protect residents from abuse and must ensure that all alleged violations involving abuse are reported immediately, but not later than two hours if they involve abuse or result in serious bodily injury, or within 24 hours if they do not result in serious bodily injury, to the administrator and to the State Survey Agency. The facility’s failure to report these incidents to CDPH as required delayed CDPH’s investigation and, as stated in the report, placed residents at risk for further abuse causing humiliation and severe injuries, including hospitalizations.
Failure to Timely Report Alleged Verbal Abuse Incident to State Agency
Penalty
Summary
The facility failed to report to the California Department of Public Health (CDPH) an alleged verbal abuse incident involving the Social Services Director (SSD) and Resident 1, as required by federal and facility policy. Resident 1, who had morbid obesity and hypertension and was assessed as having decision-making capacity and the ability to understand and be understood, was partially dependent on staff for various ADLs. On 2/3/2026, Resident 1’s family member entered the facility without a facemask and went into Resident 1’s room. The SSD saw the family member and requested that a mask be worn. When Resident 1 asked the SSD what the outbreak was, the SSD responded that Resident 1 should not worry because she was leaving the facility. Resident 1 did not like this response and called the SSD a “bitch” as the SSD was stepping out of the room. The SSD then raised her voice and asked Resident 1 why she had to be called that name, and RN 1 intervened by getting between them to calm the situation. Following the incident, Resident 1 reported that the SSD’s behavior was threatening and unprofessional and that the SSD should not be in her room. RN 2 stated she reported the 2/3/2026 verbal altercation to the Administrator (ADM) but did not know if the ADM reported it to CDPH. The ADM later stated that no one, including Resident 1, reported feelings of fear or threat or said they were scared for their life, and that if there had been such a report, she would have reported the incident to CDPH. Facility policies on abuse prevention and prohibition required reporting all abuse allegations to the State agency within required timeframes, and CMS Appendix PP required that all alleged violations involving abuse or mistreatment be reported to the State Survey Agency immediately, but not later than 2 hours after the allegation, with investigation results reported within 5 working days. Despite these requirements, the allegation that the SSD’s behavior was threatening and unprofessional toward Resident 1 was not reported to CDPH, resulting in a failure to timely report suspected abuse and the results of the investigation to the proper authorities.
Failure to Investigate Alleged Verbal Altercation Between SSD and Resident
Penalty
Summary
The deficiency involves the facility’s failure to investigate an alleged verbal altercation between the Social Services Director (SSD) and a resident, as required by the facility’s abuse investigation and reporting policies and federal regulations. The resident was admitted with diagnoses including morbid obesity and hypertension and had documented capacity to understand and make decisions. An MDS assessment showed the resident was cognitively able to understand and be understood, required varying levels of assistance with ADLs, and was dependent for some transfers and ambulation distances. On the date of the incident, a progress note documented that the SSD asked the resident’s family member to put on a face mask upon entering the resident’s room. The resident asked if there was an outbreak, and the SSD responded that she could not disclose other residents’ information. The note indicated the resident became very upset and started yelling at the SSD for not disclosing the information. As the SSD exited the room, she overheard the resident call her a “bitch,” then returned to the room and asked the resident why she had used that term. There was no documentation in the clinical record that any investigation was initiated or conducted regarding this verbal altercation. In subsequent interviews, the resident reported being afraid of the SSD and described the SSD as trying to fight with her at the beginning of the month when the incident occurred. The resident stated the SSD told her not to worry about the outbreak because she was going to leave anyway and that the SSD should not have entered her room due to multiple prior incidents. The resident further stated that during the altercation the SSD was waving her arms, yelling, asking why she was called a “bitch,” and attempting to re-enter the room, which made the resident feel threatened. The Administrator acknowledged that no investigation was conducted into the incident and stated it had been handled as a grievance instead. Facility policies on abuse prevention and prohibition require investigation of any allegations of abuse, and federal guidance in Appendix PP requires that all alleged violations be thoroughly investigated and reported to the State Survey Agency within five working days, which did not occur in this case.
Unprofessional Social Services Interaction During Outbreak Masking Dispute
Penalty
Summary
The deficiency involves the facility’s failure to ensure the Social Services Director (SSD) acted in accordance with professional standards when interacting with a resident during an infectious disease outbreak. Resident 1, who had morbid obesity and hypertension and was assessed as having decision-making capacity and the ability to understand and be understood, required varying levels of assistance with ADLs but was cognitively able to communicate needs and preferences. On the date of the incident, the SSD entered Resident 1’s room after a family member (FM1) entered without a mask during an Influenza A outbreak, and the SSD instructed FM1 to wear a mask. According to progress notes and interviews, when Resident 1 asked the SSD what type of outbreak was occurring, the SSD responded that she could not disclose that information, and per Resident 1 and RN 1, also stated that Resident 1 should not worry because she was going to leave the facility. Resident 1 became upset and, as the SSD was exiting the room, called the SSD a “bitch.” The SSD then turned back, re-entered or attempted to re-enter the room, raised her voice, and questioned Resident 1 about why she had called her that name. RN 1 reported stepping between the SSD and Resident 1 to calm the situation, and Resident 1 later stated she felt threatened by the SSD’s behavior, describing the SSD as waving her arms, yelling, and seeming like she wanted to fight. Resident 1 reported being afraid of the SSD and stated that the SSD was not supposed to enter her room due to prior unspecified incidents and that the SSD’s behavior was unprofessional and disrespectful toward someone who was bedridden. Resident 2 corroborated that Resident 1 had called the SSD a “bitch” as the SSD was leaving and that the SSD then walked back and yelled at Resident 1, asking why she had to be called that. In her own interview, the SSD acknowledged returning to the room after hearing the insult, asking Resident 1 why she had to be called a “bitch,” and later stated she probably should not have gone back into the room and should have allowed RN 1 to deescalate the situation. The surveyors concluded that the SSD’s conduct did not meet professional standards of quality and had the potential to affect Resident 1’s psychosocial well-being, leading to emotional harm.
Failure to Honor Resident Preference for Female CNA During ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s clearly documented preference not to receive ADL care from male CNAs. The resident, who had diagnoses including cerebral infarction, DM, and dementia, was determined in a recent H&P to have the capacity to understand and make decisions. Her care plan, titled “Resident Refuses Male CNA Care,” specified that she would receive required care while maintaining dignity, comfort, and emotional well-being, and directed staff to assign a female CNA for personal care, document refusals of care, and respect her preference for female CNAs. The resident’s MDS showed she required varying levels of assistance with personal hygiene, dressing, bathing, toileting hygiene, footwear, oral hygiene, and eating, indicating she depended on staff for multiple ADLs. Despite this, review of the nursing assignment sheet for a specific night shift showed that a male CNA was assigned to provide ADL care to this resident. Staff interviews confirmed that the resident’s preference to refuse care from male CNAs was widely known among facility staff. The DON acknowledged that the resident’s preference for female CNA care was in the care plan and stated that this preference should have been honored, regardless of staffing changes due to multiple staff calling out sick. The facility’s undated “Quality of Life – Dignity” policy stated that residents will always be treated with dignity and respect and that the facility is committed to honoring resident choices, preferences, values, and beliefs throughout their stay. The assignment of a male CNA in contradiction to the resident’s expressed and care-planned preference constituted the cited deficiency and was noted as having the potential to affect the resident’s psychosocial well-being.
Failure to Timely Report Influenza Outbreak to State Health Department
Penalty
Summary
The facility failed to report an influenza A outbreak to the California Department of Public Health (CDPH) within 24 hours as required by its Unusual Occurrence Reporting policy and the Los Angeles County Department of Public Health (LAC DPH) Influenza and other Respiratory Virus Diseases Outbreak Toolkit. Resident 1, who had diagnoses including heart failure, stage four chronic kidney disease, and COPD, was cognitively intact, self-responsible, and had capacity to make medical decisions per the admission record, history and physical, and MDS. Resident 1 had a positive influenza antigen test result documented on 2/2/2026 at 12:00 p.m. Resident 8, with diagnoses including diabetes mellitus, hypertensive heart disease, and pleural effusion, was documented as capable of understanding and making decisions, with the MDS indicating moderate cognitive impairment, and also had a positive influenza antigen test result on 2/2/2026 at 12:00 p.m. During interview and record review with the Infection Preventionist (IP), it was confirmed that the LAC DPH toolkit defined an outbreak as two or more laboratory-confirmed influenza cases identified within 72 hours of each other and required such outbreaks, as well as sudden increases in acute respiratory illness cases, to be reported. The facility’s Unusual Occurrence Reporting policy required epidemic outbreaks or prevalence of communicable disease to be reported via telephone to appropriate agencies within 24 hours, and the IP job description required reporting all reportable diseases to the state health department. Despite having two confirmed influenza cases that met the outbreak definition on 2/2/2026, the facility did not report the outbreak to CDPH within 24 hours, as acknowledged by both the IP and the Administrator, resulting in delayed investigation by CDPH.
Failure to Transcribe and Implement Verbal Tamiflu Order for Influenza-Positive Resident
Penalty
Summary
The facility failed to ensure that a nurse practitioner’s verbal order for Tamiflu was properly processed and implemented for a resident who tested positive for influenza. The resident, who had diagnoses including heart failure, stage four chronic kidney disease, and COPD, was cognitively intact and self-responsible, with documented capacity to make medical decisions. On 2/2/2026 around noon, the resident’s influenza antigen test was positive for Influenza A, and an SBAR documented fever of 103°F, vomiting, and coughing. The infection preventionist reported that the nurse practitioner was notified of the positive test and verbally ordered Tamiflu 75 mg twice daily for five days to treat the influenza. However, the infection preventionist stated she forgot to carry out the order and did not notify the pharmacy. Review of the resident’s physician orders and MAR for February 2026 showed no entry for Tamiflu, and nursing staff confirmed that there was no Tamiflu order documented. The nurse practitioner later confirmed that Tamiflu 75 mg had been ordered to treat Influenza A and that he was not notified that the resident did not receive the medication. The facility’s policy titled “Physician Orders” required that when receiving a telephone or verbal order, the licensed nurse must repeat the order to clarify, transcribe all components onto a telephone order form with time, date, and signature, transcribe the order onto the MAR, and notify the pharmacy of the new order. These required steps were not completed, resulting in the resident missing two doses of Tamiflu on the evening of 2/2/2026 and the morning of 2/3/2026.
Resident Kicked by CNA Resulting in Pain and Leg Discoloration
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA kicked the resident’s right shin while providing care. The resident, who had diagnoses including metabolic encephalopathy, osteoporosis, and dementia, had been assessed as lacking capacity to make decisions and having severely impaired cognitive skills for daily decision-making. The resident was dependent on staff for ADLs such as toileting and showering and required partial assistance for eating, oral hygiene, dressing, and positioning. While the CNA was in the room feeding the resident’s roommate, an RN overheard the CNA speaking to the resident and then directly observed the CNA kick the resident’s right leg. Following the observed kick, the RN immediately removed the resident from the room and the resident pointed to the right leg and stated she had been hit and was in pain. An SBAR form documented that the RN supervisor witnessed the CNA kick the resident and that the resident reported pain. A Resident Data Collection form completed later the same day documented discoloration to the resident’s right leg. The facility’s abuse, neglect, and exploitation prohibition policy stated that each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property, but the observed conduct of the CNA and resulting pain and purplish discoloration to the resident’s right shin demonstrated that this policy was not followed in this instance.
Failure to Supervise High-Risk Wanderer Resulting in Elopement and Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision and monitoring for a resident assessed as high risk for elopement and falls. The resident had dementia, Alzheimer’s disease, generalized muscle weakness, severe cognitive impairment, and a documented history of multiple prior falls. Assessments and care plans identified the resident as at risk for elopement and wandering without purpose, with exit-seeking and searching behaviors, and at high risk for falls due to poor decision making, incontinence, gait/balance problems, multiple medications, and multiple medical conditions. The care plans included interventions such as allowing safe movement in hallways, gently redirecting the resident back to supervised areas, checking the resident’s whereabouts, using a wander guard bracelet with function and placement checks every shift, providing bed and wheelchair alarms, placing the resident in visible areas after activities, providing individualized activities, encouraging the resident to ask for help, and implementing incremental monitoring for safety. Despite these identified risks and planned interventions, staff did not consistently implement or clearly define the required monitoring and supervision. The fall care plan intervention to “check resident’s whereabouts” and to provide “incremental monitoring” was described by nursing staff and the DON as vague and unclear, and there was no documentation or proof that incremental monitoring was carried out. The DON stated that the intervention for incremental monitoring was not documented and that a written log was not in place to verify implementation. The DON also acknowledged that the fall care plan intervention to place the resident in a visible area was not implemented. The RN and DON both indicated that the resident’s fall care plan interventions to prevent falls and injuries were not followed because the resident was outside the facility and unsupervised at the time of the incident. On the day of the event, the resident, who required supervision/touching assistance for transfers and ambulation and 24-hour staff assistance with mobility and daily care tasks, was able to move independently in a wheelchair around the unit. The receptionist asked an RN to observe the front door and lobby to ensure resident safety and prevent residents from leaving while the receptionist went on break. The RN reported that she did not see any residents in the lobby and left the lobby area to go to the medication room, from which the lobby and exit door could not be viewed. She did not assign another staff member to supervise the lobby and exit door. Shortly after entering the medication room, the RN heard the wander guard alarm activate at the front door. When she responded, she did not see any residents in the lobby or near the door, then ran outside and observed the resident falling on the sidewalk. Staff reported that they did not hear the resident’s wheelchair alarm prior to the fall, and the DON confirmed that the lobby and exit door were unsupervised when the wander guard alarm sounded. The resident sustained a closed head injury, left frontal scalp hematoma, intracranial hemorrhage, and fractures of the left hand fourth and fifth fingers as a result of the unwitnessed fall outside the facility after eloping without staff knowledge or supervision. Interviews with multiple staff members corroborated that the resident was not to leave the building without staff supervision and assistance, that the resident had unsteady gait and weakness, and that alarms such as wander guard and wheelchair alarms were in use but did not replace the need for active staff supervision. The Administrator acknowledged that a system-wide approach to prevent elopements and falls required active supervision of the lobby and exit door whenever the automatic-opening exit was unlocked. The facility’s own policies on Safety Supervision of Residents, Comprehensive Care Plan, and Fall Management required identification of individual risks, implementation of targeted interventions including adequate supervision, consistent implementation and evaluation of interventions, and updating care plans when falls recurred. However, the DON stated that these interventions were not correctly and consistently implemented for this resident, and that the resident’s fall and injuries were a major accident caused by lack of staff supervision and assistance when the resident exited the facility unsupervised.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Resident Unable to Access Functioning Television for Preferred Activities
Penalty
Summary
A deficiency was identified when a resident, who enjoyed watching TV as part of her preferred activities, did not have access to a functioning television in her room. The resident's care plan and activity assessment documented her interest in independent activities such as watching TV, and her medical records indicated she had moderately impaired cognition but was able to make her own decisions. During interviews and observations, it was found that the TV mounted on the wall in her room displayed static and unclear channels, making it difficult to watch. Additionally, a second TV on the nightstand was not plugged in, further limiting her ability to watch TV. The resident's family member reported that the TV was always fuzzy and unclear, and the resident herself confirmed that the TV was sometimes very unclear and difficult to watch. Staff, including an LVN, verified that both TVs in the room were either not functioning or not set up for use. Facility policies reviewed indicated an expectation for person-centered care and activities tailored to residents' interests, but these were not met in this instance, resulting in the resident being unable to enjoy watching TV as she preferred.
Failure to Honor Resident's Right to Refuse Blood Draw
Penalty
Summary
The facility failed to honor a resident's right to refuse treatment when staff attempted to draw blood from a resident who had previously indicated refusal. The resident, who had diagnoses including dementia, anxiety, and osteoarthritis, was assessed as having severely impaired cognition and was dependent on staff for daily activities. Despite physician orders and signage above the resident's bed instructing staff to call the family if the resident refused a blood draw, staff proceeded with the procedure after the resident expressed refusal. Observations and interviews revealed that the resident verbally told staff to stop during the blood draw, but staff continued and completed the procedure. The resident reported that staff held her down and did not listen to her refusal, resulting in pain and bruising on both wrists. Documentation showed that the resident had a history of refusing care, and the care plan included interventions to encourage the resident to verbalize feelings and offer understanding and empathy. Staff interviews confirmed that the protocol was to call the family if the resident refused a blood draw, and that residents should not be forced to accept care. However, the staff involved were either unaware of the signage or did not follow the established protocol. Facility policies reviewed indicated that residents have the right to refuse treatment and should not be compelled by force, but these policies were not followed in this instance.
Failure to Provide Follow-Up Dental Services for Resident Requesting Partial Dentures
Penalty
Summary
The facility failed to provide necessary dental services for a resident who requested partial dentures. The resident, who had a history of intracerebral hemorrhage and respiratory failure, was observed to have a large gap in the upper row of teeth and expressed feeling embarrassed and self-conscious due to missing teeth. Documentation showed that the resident had moderate cognitive impairment and required assistance with eating and oral hygiene. The physician had referred the resident for annual and as-needed dental consultations, and dental notes indicated the resident requested partial dentures. However, social services notes from the same date stated no recommendations were given, and there was no evidence of follow-up or provision of dentures after the resident's request. Interviews with the Social Services Director and the DON confirmed that the social services department was responsible for following up on dental evaluations and resident needs, but no follow-up dental services or dentures were provided after the initial request. The facility's policies required social services staff to make referrals, secure dental care, and document interactions, but these steps were not completed for this resident. The DON acknowledged that the lack of dentures could potentially result in weight loss and swallowing issues for the resident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease and severe cognitive impairment, who was fully dependent on staff for all activities of daily living and always incontinent of bowel and bladder, was not provided timely incontinence care. The resident's care plan required staff to clean and dry the resident after each incontinent episode and to observe for skin irritation and redness. However, according to a family member, the resident was sometimes only changed once per shift instead of the expected twice, and on one occasion was found wet with urine in both the incontinence brief and gown, indicating the brief had not been changed since the morning. Interviews with staff confirmed that leaving a resident in a wet brief can result in rashes, skin breakdown, and urinary tract infections. The Director of Nursing acknowledged that residents are to be changed at the beginning of the shift and as needed, and that failure to do so puts residents at risk. The facility's policy on bladder and bowel incontinence emphasized the importance of preventive measures for infection control, but the observed and reported practices did not align with these standards.
Failure to Provide Pain Management Evaluation
Penalty
Summary
The facility failed to provide a pain management evaluation for a resident with multiple diagnoses, including unspecified dementia, anxiety, primary osteoarthritis of both knees, and hypertension. The resident was noted to have moderate cognitive impairment and was dependent on staff for most activities of daily living. Physician orders included scheduled and as-needed pain medications, and the care plan directed staff to acknowledge pain, use non-pharmacological interventions, administer pain medication as ordered, and notify the provider if pain was not adequately controlled. Despite these orders, pain monitoring records showed the resident repeatedly reported moderate pain levels in the knees, with no documented administration of as-needed acetaminophen during the month reviewed. Progress notes indicated a referral to pain management was planned, but interviews with staff revealed that the referral was not completed and the resident had not been evaluated by a pain specialist. The DON confirmed that the resident should have been seen for pain management but was unsure why this had not occurred. The facility's policy required pain screening, evaluation, and referral to other disciplines as needed, but this process was not followed for the resident, resulting in unaddressed and unmanaged pain.
Failure to Provide Soap Dispenser in Resident Bathroom Creates Infection Control Deficiency
Penalty
Summary
A deficiency was identified when a resident's bathroom was found to be lacking a soap dispenser, with an un-labeled plastic cup containing yellow liquid placed on the sink instead. The resident in question was admitted with Alzheimer's disease and anxiety, was severely cognitively impaired, and fully dependent on staff for all activities of daily living, including hygiene and toileting. The resident was also always incontinent and at risk for developing pressure ulcers. The absence of a soap dispenser was confirmed during an observation and interview, with the resident's family member stating that there had never been soap available in the restroom. Staff interviews revealed that the Certified Nurse Aide (CNA) did not report the missing soap dispenser to the charge nurse as required, and the maintenance team was unaware of the issue, as there was no entry in the maintenance log regarding the missing dispenser. The Infection Preventionist Nurse and Director of Nursing both acknowledged that the lack of a soap dispenser and the use of a cup for soap constituted an infection control problem and a safety issue. Facility policies required regular inspection of resident rooms and bathrooms to ensure all dispensers were functioning, but this was not followed in this instance.
Failure to Arrange Transportation for Post-Surgical Follow-Up
Penalty
Summary
The facility failed to arrange transportation for a resident who required a follow-up appointment with a surgeon regarding a Jackson Pratt drain. The resident had been admitted with diagnoses including surgical aftercare following digestive system surgery, left bundle branch block, and acute on chronic systolic heart failure. The resident's Minimum Data Set indicated the ability to communicate needs and required partial to moderate assistance with personal care. A physician's order and progress notes documented the need for a follow-up appointment, and the surgeon's office communicated the appointment date to the facility. The Social Service Designee was notified to arrange transportation. However, a review of the Social Service Designee's calendar showed no documentation of transportation arrangements for the resident's appointment. On the scheduled date, the resident was unable to attend the appointment due to transportation difficulties, and the appointment was subsequently rescheduled. During an interview, the Social Service Assistant, responsible for arranging transportation, could not recall making the arrangements and was unable to provide documentation to support that transportation had been arranged. The facility's policy indicated that the Social Service Assistant is responsible for assisting with residents' transportation needs.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during wound care for three residents. During an observation, a Licensed Vocational Nurse (LVN) was seen performing wound care on Resident 2 without adhering to proper hand hygiene protocols. The LVN cleaned the bedside table, applied a plastic cover, and changed gloves multiple times without washing hands in between. Additionally, the LVN applied ointment and dressed the wound without ensuring the cleanliness of the heel protector boots, which had dried flaky skin particles inside. In another instance, the same LVN was observed conducting wound care for Resident 3. The LVN prepared the wound care supplies and donned personal protective equipment (PPE) but failed to remove the PPE before leaving the room to retrieve additional supplies. This action was contrary to the facility's policy, which requires the removal of PPE before exiting the work area. The LVN continued the wound care procedure without washing hands after changing gloves, which could lead to cross-contamination and infection. Similarly, during wound care for Resident 4, the LVN did not follow proper hand hygiene practices. The LVN left the room wearing PPE to get more supplies, which is against the facility's guidelines. The Director of Nursing confirmed that the LVN should have washed hands every time gloves were changed to prevent contamination. The facility's policy mandates handwashing after glove removal and before applying new gloves, which was not adhered to during these observations.
Failure to Recheck Low Blood Pressure in Resident
Penalty
Summary
The facility failed to recheck the blood pressure of a resident who had a physician's order of no Cardiopulmonary Resuscitation and a low blood pressure reading. The resident, who had severe cognitive impairment and was on palliative care, had a history of low blood pressure after dialysis. On a specific date, the resident's blood pressure was recorded at 93/55 mmHg with a heart rate of 53 beats per minute, leading to the withholding of blood pressure medication. During interviews, a Licensed Vocational Nurse acknowledged that the resident's baseline blood pressure was typically low after dialysis and admitted that she could have rechecked the blood pressure after 15 minutes and informed the physician. The Director of Nursing emphasized the importance of monitoring residents with low blood pressure and stated that even if the baseline was low, the blood pressure should have been rechecked and the physician informed if it remained low.
Failure to Provide Safe Environment During Wound Care
Penalty
Summary
The facility failed to provide a safe environment for a resident during wound care, which had the potential to result in a fall and injury. The resident, who was admitted with a diagnosis of a pressure ulcer in the sacral region, was identified as having cognitive impairment and one-sided impairment in both upper and lower extremities. The resident was also dependent on assistance for movement and was assessed as being at high risk for falls. During an observation, a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) raised the resident's bed to provide wound care. However, both staff members left the resident unattended with the bed raised, which was against the facility's policy for residents at high risk for falls. Interviews with the LVN and CNA confirmed that they were aware that residents should not be left alone with the bed raised, especially those at high risk for falls. The Director of Nursing (DON) also reviewed the resident's fall risk assessment and acknowledged that the resident should not have been left unattended during care. The facility's policy emphasized the importance of resident safety and supervision to prevent accidents, highlighting a failure in adhering to these guidelines in this instance.
Failure to Conduct Annual Competency Assessments
Penalty
Summary
The facility failed to ensure that a competency assessment skills check was performed upon hire and annually for two out of five randomly selected staff members. During an interview and record review, it was found that the Director of Staff Development (DSD) did not have an annual skills competency assessment check on file for a Registered Nurse (RN 1) and four Certified Nurse Assistants (CNA 1, CNA 2, CNA 3, and CNA 4). The DSD acknowledged that these assessments were necessary to validate the ability of the nursing staff and CNAs to meet the health and safety needs of the residents. The Administrator confirmed the importance of performing annual competency assessments to ensure compliance with state and federal regulations. The facility's policy and procedure indicated that competency skills evaluations should be completed upon orientation and annually thereafter. Additionally, the Facility Assessment stated that the DSD would provide ongoing training and assess competencies upon hire, annually, as needed, and on demand. The lack of these assessments had the potential to impact the facility's ability to provide nursing services while ensuring resident safety and well-being.
Deficiencies in Meal Preparation and Service
Penalty
Summary
The facility failed to meet the nutritional needs and preferences of its residents, as evidenced by several deficiencies in meal preparation and service. Resident 33, who identified as a vegetarian, was served meals containing meat, contrary to her dietary preferences. Despite being aware of Resident 33's vegetarian preference, the facility's staff, including the Certified Nursing Assistant and the Director of Dietary Services, did not ensure that her meals were appropriately adjusted. The facility's policy required food preferences to be reviewed quarterly, but this was not adhered to, leading to the resident receiving non-preferred food. Additionally, the facility did not follow standardized recipes and portion sizes for residents on mechanical soft and pureed diets. Observations revealed that 25 residents on mechanical soft diets and 20 residents on pureed diets were served incorrect portion sizes of ground meat and squash. The Registered Dietician confirmed that the portions were incorrect, which could potentially affect the residents' nutritional intake. The facility's policy on portion control was not followed, as the staff used incorrect scoop sizes due to damaged equipment, leading to improper serving sizes.
Improper Food Storage and Sanitation in Facility
Penalty
Summary
The facility failed to ensure the safe and proper storage of food items in the refrigerator, as observed during a survey. Specifically, a frozen bottled water was found unlabeled in the freezer, and several opened food items, including a bag of white sliced bread, oatmeal, grits, hot sauce, cornstarch, pickle relish, and mayonnaise, were found without open or use-by dates. Additionally, the internal fan in one of the refrigerators, which was blowing air over uncovered fresh produce, had black substances on its blades, indicating improper sanitation. Interviews with the Director of Dietary Services (DDS) and the Registered Dietician (RD) confirmed the presence of dirt on the fan and the uncovered fresh produce, which could potentially lead to cross-contamination and food poisoning. The facility's policies and procedures for food storage and maintenance were reviewed, revealing requirements for labeling food with expiration dates and maintaining clean and efficient cold storage areas. However, these policies were not adhered to, as evidenced by the observations and interviews conducted during the survey.
Inaccurate Facility Assessment and Resident Census
Penalty
Summary
The facility failed to revise and provide an updated and accurate resident census in its Facility Assessment, which is a process for evaluating the resident population and identifying the resources needed to provide care and services. During a review of the facility census on October 15, 2024, it was found that 94 residents were residing in the facility. However, during a concurrent interview and record review on October 18, 2024, with the Administrator, it was revealed that the Facility's Assessment was last updated on September 7, 2024, and indicated an average daily census of 88 to 91 residents. This discrepancy between the recorded census and the actual number of residents was acknowledged by the Administrator, who admitted that the Facility Assessment did not match the current census and that some residents were not accounted for in the assessment. The Administrator stated that she was responsible for updating the Facility Assessment, which serves as an overview of the services provided by the facility to the resident population. The incorrect documentation on the Facility Assessment could potentially result in not providing quality and standard care to residents. The Centers for Medicare and Medicaid Services (CMS) guidance, referenced as QSO-24-13-NH, requires that the facility assessment include an evaluation of the resident population's diseases, conditions, and limitations, and be updated as necessary and at least annually. The failure to maintain an accurate and updated Facility Assessment could place residents at risk for delays in care and treatment services.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program by not monitoring and addressing antibiotic use for a resident who was on antibiotics for a urinary tract infection (UTI). The resident, who had a history of UTI, sepsis, and diabetes mellitus, was readmitted to the facility from a hospital with a prescription for Bactrim DS to treat the UTI. Despite the facility's policy requiring infection surveillance within three days of admission, the Infection Preventionist Nurse (IPN) did not complete the surveillance form for the resident, and no laboratory specimens were drawn at the facility after the resident's discharge from the hospital. The Director of Nursing (DON) acknowledged that the lack of surveillance could lead to unnecessary antibiotic use, potentially causing harm such as antibiotic resistance or adverse reactions. The facility's policy on the Antibiotic Stewardship Program outlined specific steps for infection surveillance, including monitoring the type of antibiotic ordered, the route of administration, and whether a culture was obtained before ordering the antibiotic. However, these steps were not followed for the resident, leading to the deficiency identified in the report.
Failure to Reassign CNA After Grievance
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA 5) was not assigned to a resident (Resident 195) after a grievance was filed by the resident's family member regarding the CNA's loud and rude behavior. Resident 195, who was admitted with multiple fractures and was fully dependent on staff for daily activities, experienced a lack of dignity and respect from CNA 5, as reported by the resident and confirmed by the family member's grievance. Despite the grievance, CNA 5 continued to be assigned to Resident 195 for three days after the grievance was filed. Interviews with the Social Services Director, Registered Nurse Supervisor, Director of Staff Development, and Human Resources Staffing Coordinator revealed that the grievance was acknowledged, and it was agreed that CNA 5 should have been removed from providing care to Resident 195. However, the intervention to remove CNA 5 was not implemented, leading to continued interaction between CNA 5 and Resident 195. The facility's policy on dignity, which requires staff to speak respectfully to residents, was not adhered to in this case.
Failure to Notify Resident of Found EBT Card
Penalty
Summary
The facility failed to notify a resident, her doctor, and a family member when her missing Electronic Benefit Transfer (EBT) card was found. The resident, who was admitted with diagnoses including metabolic encephalopathy, chronic kidney disease, and dementia, had a severely impaired cognitive ability and required substantial assistance from staff. The EBT card, valued at $190, was reported missing by a Certified Nursing Assistant (CNA) to the resident's responsible party, who was informed during a visit. The resident expressed worry about the missing card, and the CNA reported the issue to the registered nurse supervisor. The Activities Director later found the EBT card in the activity room but failed to notify the staff or the resident, which prolonged the resident's distress. The registered nurse stated that the lack of communication among staff delayed the resolution of the issue and increased the resident's distress. The facility's policy on residents and personal property requires reports of misappropriation or mistreatment of resident property to be investigated and documented, but this process was not followed in this instance.
Failure to Address Resident's Grievance for Missing EBT Card
Penalty
Summary
The facility failed to ensure that a resident was offered the opportunity to file a grievance regarding a missing Electronic Benefit Transfer (EBT) card. The resident, who was admitted with diagnoses including metabolic encephalopathy, chronic kidney disease, and dementia, had a severely impaired cognitive ability and required substantial assistance from staff. The resident's EBT card, valued at $190, was noted as missing by a Certified Nursing Assistant and reported to the resident's responsible party. However, the Social Services Director and the Director of Nursing were not aware of the missing card, and the grievance process was not initiated as required by the facility's policy. The facility's policy mandates that grievances be actively resolved and communicated to the resident or their family in a timely manner. Despite this, the grievance process was not followed, and the resident was not given the opportunity to file a grievance for the missing EBT card. This oversight had the potential to cause distress for the resident, as acknowledged by both the Social Services Director and the Director of Nursing during their interviews. The facility's failure to adhere to its grievance policy resulted in a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.
Inaccurate MDS Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) Section A for the level II Preadmission Screening and Resident Review (PASRR) condition for two residents. Resident 42's admission record indicated diagnoses including schizophrenia, dementia, osteoarthritis, and anemia. However, the MDS did not acknowledge the schizophrenia diagnosis, which was confirmed by the MDS Nurse during an interview. The nurse admitted that the MDS was inaccurate and emphasized that such inaccuracies could lead to poor quality of care. Similarly, Resident 85's MDS assessment was completed inaccurately. The resident's diagnoses included schizoaffective disorder, chronic kidney disease, and dysphagia. The MDS Nurse noted that the cognitive skills for daily decision-making were severely impaired, and the PASRR sections A1500 and A1510 were incorrectly coded. The nurse stated that the assessment should have indicated a serious mental illness due to the schizoaffective disorder diagnosis. The facility's policy requires that any person completing a portion of the MDS must certify its accuracy, which was not adhered to in these cases.
Failure to Resubmit PASRR for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) was resubmitted for two residents, leading to a potential deficiency in their mental health care. Resident 42, who was admitted with diagnoses including schizophrenia and dementia, had a severely impaired cognitive ability and was dependent on staff for daily activities. Despite these conditions, the PASRR was not resubmitted, which could have resulted in a lack of necessary mental health resources and services. The MDS Nurse acknowledged that the PASRR should have been resubmitted due to the resident's mental illness diagnosis. Similarly, Resident 85, diagnosed with schizoaffective disorder and receiving psychotropic medication, had an inaccurately completed PASRR level 1 screening by the general acute care hospital. The screening failed to recognize the serious mental illness and the use of psychotropic medication, which should have triggered a PASRR level 11 evaluation. The MDS Nurse confirmed that the facility should have completed and resubmitted a new PASRR level 1 screening to ensure the resident received appropriate treatment recommendations. The facility's policy indicated that designated staff should review PASRRs from acute hospitals and determine necessary follow-ups, which was not adhered to in these cases.
Failure to Develop Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop a person-centered care plan for two residents, leading to deficiencies in addressing their specific needs. For Resident 83, who was diagnosed with major depressive disorder, anxiety disorder, and a mental disorder, the facility did not create a comprehensive care plan to address the resident's smoking habits. Despite the resident's intact cognitive skills and the need for supervision while smoking, as indicated in the smoking assessment and evaluation, no care plan was documented. The MDS Nurse acknowledged the absence of a care plan and emphasized its importance for the safety of staff and other residents. For Resident 195, who was fully dependent on staff for daily activities and had intact cognitive skills, the facility failed to develop a care plan following grievances filed by the resident's family member. The grievances involved a CNA being loud and rude during care. Despite the grievances being logged, no care plan was created to address the incident. RN 1 confirmed the lack of a care plan related to the grievance, which could potentially delay adequate care for the resident. The facility's policy requires comprehensive care plans to be developed and evaluated in response to changes in a resident's status, but this was not adhered to in these cases.
Failure to Clean and Provide Dentures to Resident
Penalty
Summary
The facility failed to ensure that a resident's dentures were cleaned daily, which led to the resident feeling frustrated. The resident, who was blind and had fluctuating capacity to understand and make decisions, required substantial assistance from staff for personal hygiene and showering. Despite this need, the resident reported that staff did not clean the dentures daily nor place them within reach before meals, making it difficult for the resident to determine if the dentures were clean. This lack of assistance was confirmed during interviews with the resident and observations by surveyors, where it was noted that the dentures were not offered during meals and were not within reach. The Director of Nursing (DON) acknowledged that certified nursing assistants (CNAs) were responsible for soaking the dentures at night, cleaning them in the morning, and placing them within reach. However, this procedure was not followed, as confirmed by a CNA who admitted the dentures were in a drawer and not accessible to the resident. The facility's policy and procedure for denture care emphasized the importance of cleaning dentures to remove plaque and odor, and to encourage residents to wear them to facilitate eating and speaking. Despite these guidelines, the facility did not adhere to its own policies, resulting in the resident's frustration and inability to use the dentures effectively.
Failure to Schedule Ophthalmology Appointment for Resident
Penalty
Summary
The facility failed to schedule a follow-up ophthalmology appointment for a resident who required evaluation for cataracts and glaucoma. The resident, who was admitted with diagnoses including schizoaffective disorder, chronic kidney disease, and dysphagia, was found to have impaired vision and lacked the capacity for medical decision-making. An eye consultation indicated the need for a referral to an ophthalmologist, but this was not scheduled. During interviews, the resident expressed concerns about worsening vision and the delay in receiving new eyeglasses. The Social Service Director, responsible for scheduling such appointments, was unaware of the need for the ophthalmology referral and acknowledged the absence of documentation or follow-up. The facility's policies indicated that social services should manage referrals for vision care, but this was not adhered to, potentially delaying necessary treatment for the resident.
Incorrect LAL Mattress Setting for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident had the correct low air loss (LAL) mattress setting, which is crucial for preventing pressure ulcer development. The resident, who was at high risk for skin breakdown due to severe cognitive impairment and dependency on staff for personal care, had their LAL mattress set incorrectly at 400 pounds instead of their actual weight of 101 pounds. This incorrect setting was identified during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged the error and its potential risk for skin breakdown. The resident's medical history included conditions such as failure to thrive, dementia, and chronic obstructive pulmonary disease, which further increased their vulnerability to pressure ulcers. The facility's policy on low air loss therapy beds emphasized the importance of setting the mattress to specific pressures based on the patient's height and weight. Interviews with the LVN and the Minimum Data Set (MDS) Nurse confirmed the significance of correct mattress settings in maintaining skin integrity and preventing pressure ulcers, highlighting the deficiency in care provided to the resident.
Failure to Provide Correct Diet Texture for Resident Without Dentures
Penalty
Summary
The facility failed to provide the correct diet texture for a resident who did not wear dentures, which could potentially affect the resident's ability to chew food properly. The resident, who was blind and had fluctuating capacity to understand and make decisions, was on a low sodium regular diet. Despite the resident's inability to wear dentures due to difficulty in putting them in, the facility did not adjust the food texture to accommodate this, leading to challenges in chewing, especially with meat. Interviews with the Registered Dietitian and the Minimum Data Set Nurse revealed that the resident's diet should have been adjusted to a texture suitable for someone not wearing dentures. The Registered Dietitian emphasized the importance of assisting the resident with wearing dentures due to his blindness and the risk of weight loss if the food texture was too hard. The facility's policy and procedure indicated the need for special nutritional requirements and equipment, but these were not adequately implemented for the resident.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident diagnosed with post-traumatic stress disorder (PTSD), major depressive disorder, and anxiety disorder. The resident, who had experienced a traumatic event with the loss of his wife to cancer, was not given the necessary psychosocial support as outlined in the facility's policies. Despite the resident's cognitive skills being intact and his ability to make medical decisions, the care plan did not address his trauma-related needs, and staff did not offer group therapy or other interventions to help manage his emotional distress. The Social Service Director acknowledged the importance of screening residents for trauma history to prevent re-traumatization and improve their quality of life. However, the facility did not implement any interventions to address the resident's past traumatic experience. The facility's policies emphasized the need for trauma-informed care and psychosocial support, but these were not provided to the resident, leading to a deficiency in care.
Failure to Follow Physician Orders for Oxygen Settings
Penalty
Summary
The facility failed to ensure that staff followed physician orders for the correct oxygen settings for Resident 12, who was admitted with diagnoses including emphysema, end-stage renal disease, and heart failure. The resident's Minimum Data Set indicated severe cognitive impairment, requiring substantial assistance from staff. During an observation, it was noted that the resident's oxygen concentrator was set at three liters per minute, contrary to the physician's order of two liters via nasal cannula. Licensed Vocational Nurse (LVN) 1 confirmed that the oxygen setting was incorrect and acknowledged the importance of adhering to physician orders to prevent potential harm, such as exacerbating the resident's emphysema. The Minimum Data Set Nurse also emphasized that oxygen settings are considered a medication and must be administered as per the physician's orders. The facility's policies on physician orders and medication pass guidelines were reviewed, highlighting the necessity for accurate implementation of physician orders to ensure proper resident care.
Failure to Provide Emotional Support and Social Services to Grieving Resident
Penalty
Summary
The facility failed to provide medically related social services and emotional support to a resident, identified as Resident 83, who was grieving the loss of his wife. Resident 83 was admitted to the facility with diagnoses including major depressive disorder and anxiety disorder. Despite having intact cognitive skills and the capacity for medical decision-making, the resident expressed ongoing grief and a desire to participate in group therapy to share his experiences. However, the facility did not offer daily supportive visits, emotional support, or group therapy, nor was the resident referred to a psychologist since his admission. The Social Service Director (SSD) acknowledged the lack of documentation and interventions provided to Resident 83, admitting there was no reason for the failure to refer the resident to a psychologist. The SSD recognized that this oversight could lead the resident to feel neglected and at risk for further depression. The facility's policies indicated that residents displaying mental or psychosocial adjustment difficulties should receive appropriate treatment and services, which were not provided in this case.
Failure to Act on Pharmacy Consultant's Recommendation
Penalty
Summary
The facility failed to ensure that a pharmacy consultant's recommendation for a trial reduction of a psychotropic medication was acknowledged and acted upon for Resident 83. The consultant pharmacist had recommended a trial reduction of Seroquel, a medication prescribed for paranoia, during a Medication Regimen Review. However, the facility did not inform Resident 83's physician of this recommendation, and no action was taken to address the suggestion. This oversight was identified during a review of Resident 83's clinical records, where it was noted that the pharmacy consultant's recommendation note was not signed or dated by the physician. Resident 83, who was admitted to the facility with diagnoses including major depressive disorder and anxiety disorder, had intact cognitive skills for daily decision-making and required setup assistance for certain activities. Despite the consultant pharmacist's recommendation, the facility's Director of Nursing acknowledged that the facility failed to follow its policy and procedure for Medication Regimen Review and Reporting, which mandates that recommendations be documented and acted upon within 30 days. This deficiency had the potential to result in Resident 83 receiving unnecessary medication.
Failure to Label Expiration Date on Tuberculin Vial
Penalty
Summary
The facility failed to ensure that an opened multi-dose tuberculin vial was labeled with an expiration date in the medication storage room. During an observation and interview, a multidose vial of tuberculin purified protein derivative was found in the refrigerator with a date but no expiration date. A registered nurse acknowledged that the vial was just opened and should have been labeled with an expiration date. The nurse also noted that the date on the vial box could be confusing and mistaken for an expiration date instead of an open date. This oversight had the potential to lead to administering expired medication or a medication error. The facility's policy and procedures for medication storage, which were undated, indicated that refrigerated medications should be kept in closed and labeled containers. However, the observed practice did not align with this policy, as the tuberculin vial was not properly labeled with an expiration date.
Failure to Date and Label Oxygen Humidifier
Penalty
Summary
The facility failed to ensure that the oxygen humidifier for one of the residents was properly dated and labeled, which is a critical step in infection prevention and control. During an observation and interview, it was noted that the oxygen humidifier in the resident's room was neither dated nor labeled. The Licensed Vocational Nurse (LVN) acknowledged this oversight and stated that the humidifier should be changed weekly. The absence of a date and label on the humidifier posed a risk of bacterial contamination, potentially leading to a respiratory infection for the resident. The resident in question had significant medical conditions, including emphysema, end-stage renal disease, and heart failure, and was severely cognitively impaired, requiring substantial assistance from staff for personal care. The Director of Nursing (DON) confirmed that the facility's policy required humidifiers to be changed every seven days or as needed, and that they should be labeled and dated upon opening. The failure to adhere to this policy meant that staff could not determine when the humidifier was last changed, increasing the risk of infection for the resident.
Failure to Individualize Care Plans for Fall Risk Residents
Penalty
Summary
The facility failed to ensure that the care plans for two residents at risk for falls were revised and individualized to include the level of staff assistance needed for safe transfer and mobility. Resident 1, who was admitted with conditions such as osteopenia, bradycardia, and syncope, had a care plan that did not specify the level of assistance required for transfers and mobility, despite being identified as high risk for falls. The physical therapist's discharge summary indicated that Resident 1 needed contact guard assistance for transfers, but this was not reflected in the care plan. Additionally, Resident 1 experienced a fall incident, and the risk meeting notes highlighted the need for assistance with toileting and unstable gait and balance. Similarly, Resident 3, admitted with diagnoses including radiculopathy, spinal stenosis, and neuralgia, had a care plan that failed to specify the level of assistance needed for transfer and mobility. The care plan identified Resident 3 as high risk for falls due to muscle weakness and balance problems. The MDS indicated that Resident 3 required substantial assistance with activities of daily living, and the physical therapist's treatment notes specified the need for partial/moderate assistance for transfers and ambulation. However, these details were not included in the care plan. Interviews with the RN and DON revealed that care plans should be individualized based on residents' needs for assistance, and the lack of specificity in the care plans could lead to increased fall risks. The facility's policies emphasized the importance of a resident-centered fall prevention plan and comprehensive care plans that address individual needs and prevent avoidable decline. However, the care plans for Residents 1 and 3 did not meet these standards, resulting in a deficiency.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to provide necessary assistance to a resident, identified as Resident 3, who was assessed as needing partial/moderate assistance after toileting and while ambulating. Resident 3, who had medical conditions including radiculopathy, spinal stenosis, and neuralgia, was at high risk for falls due to muscle weakness and balance problems. Despite this, the resident's care plan and Minimum Data Set indicated a need for substantial assistance with activities of daily living. On the day of the incident, a Certified Nurse Assistant (CNA) took Resident 3 to the bathroom with a walker, but did not maintain the required close proximity and physical support, resulting in the resident losing balance and falling. Interviews with the resident, CNA, Rehabilitation Supervisor, and Director of Nursing revealed that the CNA was not in the correct position to provide the necessary support, as she was in front of the resident and not holding her. The facility's policies on safety supervision and fall management emphasized the importance of providing adequate supervision and assistance to prevent accidents, which was not adhered to in this case. The failure to follow these protocols led to the resident's fall, highlighting a deficiency in the facility's adherence to its own safety and fall prevention policies.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in an incident where one resident was pushed to the floor and sustained a hematoma on the forehead. The facility did not follow the care plan and physician's orders for monitoring and addressing aggressive behaviors of the resident who committed the abuse. This resident had a history of physical aggression, including a previous altercation with the same resident, but the facility did not ensure they were separated or supervised adequately. The care plan for the aggressive resident was not individualized to address specific triggers and behaviors, such as not receiving what the resident wanted immediately. Despite multiple episodes of agitation and aggression, the facility failed to notify the physician or implement effective interventions. The facility's policies and procedures for abuse prevention and behavior monitoring were not followed, as there was no documentation of physician notification or other interventions when redirection was ineffective. Interviews with staff revealed that the aggressive resident was known to be physically aggressive and had previously hit staff members. The Director of Nursing acknowledged that the residents should have been kept separated and that the care plan should have been individualized to include specific triggers and supervision needs. The facility's policies emphasized the importance of individualized interventions and immediate safety strategies to protect residents, but these were not implemented effectively in this case.
Failure in Resident Supervision and Elopement Prevention
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding resident elopement and safety supervision, resulting in a resident leaving the facility unsupervised. The resident, who had a history of dementia, anxiety disorder, hypertension, and osteoarthritis, was assessed to be at risk for wandering and elopement. Despite this, the resident was able to leave the facility without supervision. The resident's care plan included interventions to check the resident's whereabouts, and a wander guard was ordered and placed on the resident to prevent elopement. However, on the day of the incident, staff members did not hear the alarm from the wander guard, indicating a failure in the system designed to prevent such occurrences. Interviews with staff revealed that the resident was not accounted for at the beginning of a shift, and the alarm system did not function as expected. A CNA admitted to not visually confirming the resident's presence, and an LVN acknowledged the importance of supervising residents at risk for elopement but did not recall hearing the alarm. The Director of Nursing confirmed that the wander guard should have alarmed when the resident approached an exit, but no alarm was heard. This oversight in supervision and failure of the alarm system contributed to the resident's unsupervised departure from the facility.
Failure to Obtain Physician Order for Resident's Out on Pass
Penalty
Summary
The facility failed to obtain a physician order to allow a resident to leave the facility on out on pass. This deficiency was identified during an interview and record review, where it was found that the resident, who had a history of acute kidney failure, an automatic cardiac defibrillator, and hypertension, had been leaving the facility frequently without a physician's order. The resident's Minimum Data Set indicated that they were independent in certain activities but had a care plan noting the risk of injury due to medical conditions such as hypertension and venous ulcers. Despite this, the resident signed out and left the facility multiple times from January to March 2024 without the required physician order. During a review of the facility's policies, it was noted that all residents leaving the facility must have a physician order indicating they are medically stable to go out on pass. However, the physician order reports from January to April 2024 did not include any such order for the resident. The Director of Nursing acknowledged that the resident's safety might have been compromised due to this oversight. The facility's policy on physician orders also emphasized the need for clear direction in the care of residents, which was not followed in this case.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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