Meadowood Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clearlake, California.
- Location
- 3805 Dexter Lane, Clearlake, California 95422
- CMS Provider Number
- 555490
- Inspections on file
- 33
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Meadowood Nursing Center during CMS and state inspections, most recent first.
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.
Two cognitively intact residents engaged in repeated verbal and physical abuse at the nurse’s station and in a hallway, including one resident pushing her wheelchair into another, using profanity, and the other intentionally kicking her in the knee and later making obscene gestures and derogatory remarks. Staff, including CNAs, witnessed the initial altercation and a later hostile exchange near a resident’s doorway but did not promptly intervene or separate the residents, despite facility policies defining kicking and disparaging language as abuse and job descriptions requiring CNAs and RNs to protect residents from abuse.
A resident with a history of traumatic subdural hemorrhage, rib fractures, and repeated falls experienced an unwitnessed fall with head strike. CNAs reported finding the resident on the floor by his bed, assisting him back to bed with an RN, and later observing facial discoloration and complaints of head pain, which were noted by the resident’s spouse. Hospital records documented that the resident reported an unwitnessed fall with head strike at the SNF and was admitted with an enlarging subdural hematoma. However, the facility’s records for that day contained no fall entry, no post-fall assessment, no MD or emergency contact notification, no alert charting, and no care plan update, despite policies requiring evaluation, documentation, change-in-condition notification, and care plan revision after falls and incidents.
A resident with cervical radiculopathy and depression lived in a room where the privacy curtain and the ceiling above the bed remained visibly soiled for many months, including brown smears, dark gray splatter-like spots, a white crusty substance on the curtain, and a brown splatter identified as chocolate pudding on the ceiling. The resident reported the curtain had not been washed for over a year and expressed frustration that staff were not maintaining a clean living space. The Environmental Services Supervisor confirmed the stains, acknowledged they needed cleaning, and stated that while spot checks were performed, neither she nor the housekeeper typically looked up to notice ceiling or upper-surface soiling. She also reported that a deep clean routine, which includes washing privacy curtains, had only recently been implemented and that there had previously been no set schedule for curtain washing or deep cleaning, despite facility policy requiring a clean, sanitary, homelike environment.
A resident with substance dependence and no memory impairment had a physician’s order for Suboxone sublingual film three times daily for opioid dependence. Over two days, three ordered doses were not administered because the medication was unavailable, with documentation indicating the drug was pending pharmacy delivery and the order was awaiting physician signature. The resident reported not receiving Suboxone for about a week and experiencing shaking and anxiety, and the ADON confirmed the missed doses and lack of medication availability, acknowledging this as a significant medication error in light of facility policies requiring timely provision of medications and an environment free of significant medication errors.
A resident with HTN and Type II DM, who had a physician order indicating capacity to understand rights and make decisions, requested to leave the facility one evening but was not allowed to discharge. Nursing staff told the resident it was too late, cited safety concerns, and did not know the discharge procedure, and no administrative staff were contacted. The resident was not offered a release of responsibility form as required by facility policy for discharges without physician approval. Multiple staff, including the SSD, ADON, and DSD, later confirmed the resident was responsible for his own decisions and should have been allowed to leave, and the resident reported feeling very upset and frustrated when his request to go home was denied.
A resident with HTN and Type II DM was suspected by multiple staff and the resident’s son to be experiencing financial exploitation by a caregiver who held and possibly used the resident’s credit card. The SSD, ADON, and an LN each acknowledged that the situation constituted suspected financial abuse that warranted reporting, but no report was made to law enforcement, the LTC ombudsman, or CDPH. This inaction conflicted with the facility’s abuse and exploitation policy and state mandated reporting requirements, which require identification, investigation, and timely reporting of suspected abuse or exploitation by any individual.
A resident admitted with unsteadiness in feet and dysphagia had an active physician order for an alternating pressure pad (APP) mattress, but surveyors observed the resident on a regular mattress. Nursing staff acknowledged that physician orders must be followed, confirmed the resident had fragile skin and was at risk for pressure ulcers, and the ADON verified the APP order had not been implemented despite a Braden score indicating risk. Facility policies required use of appropriate support surfaces based on risk factors and adherence to prescribers’ orders, but no specific policy on physician orders was provided when requested.
A medication security deficiency occurred when an LN left a hall medication cart unlocked and unattended while inside a resident’s room, with no other staff present to monitor the cart. The LN later confirmed the cart had been left unlocked, despite facility policy requiring carts to remain closed and locked whenever out of the nurse’s sight. The ADON also confirmed that policy mandates locking unattended carts to prevent unauthorized access to medications, and the written medication administration P&P specifies that the cart must be kept closed and locked when not in direct view of the medication nurse or aide.
Two residents experienced lapses in infection control when staff failed to follow facility policies. For one resident with unsteadiness and dysphagia, an LN picked up three pillows from the floor and placed them back on the bed, despite leadership acknowledging that items on the floor are considered contaminated. For another resident with COPD and emphysema receiving scheduled nebulizer treatments, the nebulizer mouthpiece was left on a bedside dresser near beverages and a used cup instead of being rinsed, disinfected, and stored in a labeled plastic bag as required by facility policy. These actions did not comply with the facility’s infection prevention and nebulizer equipment procedures.
A resident with a PICC line and orders for daily heparin flushes and shift-based monitoring for infection did not have these treatments and assessments consistently documented on the MAR over multiple days. A non-RN licensed staff member reported he could not perform the flushes himself and only reminded RNs, with no confirmation they completed the tasks, and PICC site monitoring was not consistently charted. The resident stated that PICC care occurred less than half as often as ordered despite repeated reminders, and the DON confirmed that missing documentation meant the ordered PICC line care was not completed.
A resident with a diagnosis of left eye keratitis did not receive several prescribed doses of an ophthalmic solution, and there was no documentation in the MAR or medical record explaining why the medication was not administered. Interviews with the DON and Administrator confirmed that this lack of documentation did not meet facility policy, which requires reasons for missed medications to be recorded.
A resident with a history of cellulitis and venous insufficiency had acetaminophen left at her bedside without a physician's order for self-administration, resulting in the medication not being taken and her condition worsening. Additionally, staff were found to have pre-prepared medications for multiple residents, leaving unidentified medications in the medication cart, with the DON aware and instructing staff to supervise administration of these pre-prepared doses. These actions were not in accordance with facility policy and increased the risk of medication errors.
A resident with a history of cellulitis and venous insufficiency experienced a significant change in condition, including high fever, altered mental status, and worsening leg redness. Despite these symptoms being recognized by staff during the morning shift, the physician was not notified until several hours later. The delay in notification and lack of documentation led to delayed care and hospitalization for fever, altered consciousness, and sepsis, constituting neglect as defined by facility policy.
A nurse failed to maintain a resident's dignity and privacy during the administration of a rectal suppository by not stopping the procedure when the resident expressed pain and requested it be stopped, not ensuring privacy by leaving the curtain and door open, and not providing an adequate explanation of the procedure beforehand. The resident experienced pain, embarrassment, and psychological trauma as a result.
A registered nurse performed a digital stool dis-impaction on a resident without a physician's order during the administration of a rectal suppository, resulting in the resident experiencing pain, distress, and ongoing psychological trauma. The facility lacked adequate staff training, competency documentation, and policies regarding rectal medication administration and digital dis-impaction, leading to inconsistent practices among nursing staff.
A resident with a history of post laminectomy syndrome and constipation reported feeling violated after a nurse administered a rectal suppository in a manner the resident found inappropriate. Although facility policy required immediate reporting of abuse allegations within two hours, there was no evidence that the incident was reported to the Department within the required timeframe, and the Department did not receive notification until the following day.
A CNA solicited and received a debit card and PIN from a resident with multiple medical conditions, using the card to withdraw money after expressing financial hardship. The resident, who had no memory impairment, expected repayment but did not hear from the CNA afterward and reported feeling taken advantage of. Facility policy prohibits staff from accepting gifts, loans, or financial dealings with residents, and staff interviews confirmed awareness of these rules.
The facility failed to issue Notices of Medicare Non-Coverage (NOMNC) to two residents prior to their discharge, despite receiving Medicare Part A services. Staff interviews revealed a lack of clarity and accountability regarding the issuance of these notices, with key personnel unable to explain the oversight.
A resident with a history of pulmonary issues was using an Acapella device without a physician's order, contrary to facility policy. Staff interviews revealed a lack of awareness and oversight, as the device was not documented or ordered until noted by a surveyor. The facility's protocol required a physician's order for such devices, which was not initially obtained.
A resident sustained a left femoral fracture after a fall during a transfer using a mechanical lift, as only one staff member assisted instead of the required two. The staff member involved had not completed the necessary competency test for using the lift. The facility's policy, which mandates two staff for such transfers, was not followed, leading to the resident's injury.
Two residents in an LTC facility experienced injuries due to inadequate supervision and delayed response to call lights. One resident, requiring assistance for mobility, fell and fractured his arm after waiting over twenty minutes for help to use the toilet. Another resident, allowed to smoke unsupervised, sustained burns when his pants caught fire. Staff interviews revealed inconsistencies in following facility policies for call light response and smoking supervision.
A resident with chronic pain and a recent hip replacement experienced unmanaged pain due to the facility's failure to administer pain medication on time. The resident's medications, including Oxycodone and Norco, were frequently given late, contrary to the facility's policy of administering within one hour of the scheduled time. Interviews with staff confirmed the policy but revealed inconsistencies in its implementation, leading to the resident's significant discomfort.
The facility failed to provide scheduled showers to three residents, compromising their hygiene needs. A resident admitted for physical therapy after hip replacement did not receive showers for weeks, despite requiring partial assistance. Another resident with Alzheimer's and Parkinson's diseases, dependent on staff for showers, had no shower logs for two months. A third resident, needing setup assistance, reported not receiving showers for two weeks, leading to discomfort. Staff interviews revealed inconsistencies in providing showers outside scheduled days, and the facility lacked proper documentation, violating its hygiene policy.
Two residents experienced significant negative outcomes due to delayed call light responses in an LTC facility. One resident, requiring moderate assistance, fell and fractured an arm after waiting over twenty minutes for help. Another resident, needing substantial assistance, developed moisture-associated skin damage from prolonged exposure to moisture due to similar delays. Staff interviews confirmed the facility's policy of responding within five minutes was not consistently followed.
A resident in an LTC facility received pain medications Oxycodone and Oxycontin more frequently than prescribed, despite facility policies requiring verification of the right medication and dosage. The resident, with a history of chronic pain and recent hip surgery, was at risk due to these significant medication errors.
A resident's call light system was found to be non-functional, posing a risk of unmet needs. Despite daily checks, the issue was not reported or addressed until observed by staff. The resident, with cognitive intactness and requiring assistance, relied on another resident to signal for help. The malfunction was due to dirt obstructing the connection, which was resolved after cleaning.
A facility failed to accurately complete the MDS for a resident, resulting in incomplete information necessary for a resident-centered care plan. The resident, admitted with mobility issues, had an MDS indicating a BIMS score of 14, but key areas like eating and hygiene were not assessed. The MDS Coordinator acknowledged the inaccuracies, which contradicted the facility's policy on comprehensive assessments.
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 Prevent and Intervene in Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse during and after a resident‑to‑resident altercation that included profanity and physical contact. One resident with COPD and major depressive disorder, who had an intact BIMS score of 13, was involved in an incident at the nurse’s station with another cognitively intact resident who had hemiplegia/hemiparesis following a cerebral infarction and heart failure. According to the facility’s own post‑event note and SBAR forms, the first resident wheeled up to the nurse’s station where the second resident was already seated, pushed her wheelchair into the second resident, and told her to “fuck off” when asked to stop. The second resident then kicked the first resident in the left knee. Staff, including two CNAs, witnessed the incident, and documentation identified the second resident as the aggressor who intentionally kicked the other resident’s knee. Interviews with both residents confirmed the verbal and physical nature of the altercation and that it occurred in front of staff. The first resident reported that the second resident was in her way at the nurse’s station, that she was kicked in the left knee, that it hurt, and that staff did not respond immediately to the incident. The second resident stated that the first resident told her to “get the fuck out of my way” and continued yelling, and that she kicked toward the first resident to get her away, striking her knee. The second resident also reported that, after the incident, she would give the first resident the middle finger when she passed by, and that the first resident would sit outside her room and call her a “fucking bitch.” Surveyor observation showed that the antagonistic interactions between the two residents continued without staff intervention. On one occasion, the first resident stopped in front of the second resident’s doorway, the second resident yelled “Keep going!”, and the first resident responded “Oh yea!” and continued down the hallway while a staff member seated about 10 feet away paid no attention to the interaction. Staff interviews, including with a CNA, confirmed that the kick was intentional and that the second resident could verbalize her needs instead of kicking. The Social Service Director and ADON both characterized the incident as verbal and physical abuse under the facility’s abuse policy, which defines physical abuse to include kicking and verbal abuse to include disparaging and derogatory terms, and job descriptions for CNAs and RNs require them to protect residents from abuse. Despite these definitions and responsibilities, staff did not promptly intervene to separate the residents or prevent ongoing verbal and gestured abuse.
Failure to Document and Respond to Resident Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to document and respond to a resident fall and associated change in condition in accordance with its policies and fall protocol. Resident 4, who had a history of traumatic subdural hemorrhage, multiple rib fractures, and repeated falls, was cognitively intact with a BIMS score of 13. On a prior date in March, he had a witnessed fall with head strike, was sent to a general acute care hospital (GACH), and imaging showed an acute on chronic subdural hematoma with a 4 mm shift; he was later returned to the SNF in stable condition. These clinical details established that the resident was at high risk for serious injury from any subsequent head trauma. On a later date in April, hospital records from the GACH emergency department documented that the resident reported an unwitnessed fall at the SNF with a positive head strike. A critical care consult note from the same hospitalization stated that he had previously fallen in March with a subdural hematoma and that he presented again after an unwitnessed fall in the SNF in which he hit his head, and was transferred for a new, enlarging left-sided subdural hematoma with mass effect, brain compression, and shift. Despite this, the SNF’s electronic medical record for that April date contained no evidence that a fall had occurred, and no documentation of a status-post-fall assessment, MD notification, emergency contact notification, alert charting, or an updated care plan. Interviews with facility staff further described the events of the day of the unwitnessed fall. One CNA stated that another CNA requested help to pick the resident up from the floor and that the assigned nurse, identified as LN 1, also responded; they assisted the resident from a crouched position by his bed back into bed. The same CNA later accompanied the resident to a doctor’s appointment, where the resident’s wife noticed one side of his face was discolored and red; the CNA observed reddish-pinkish discoloration on one side of the resident’s face and heard the resident tell his wife that his head hurt, after which the wife wanted him to go to the hospital. Another CNA reported that when she responded to the resident calling for help, she found him on the floor next to his bed, and he told her he had fallen; she then retrieved his nurse, who assessed him, and the CNA left the room. The administrator confirmed that LN 1 was the resident’s nurse on that day and that there was no documentation in the resident’s record of a fall or related assessments or notifications, despite facility policies requiring evaluation, documentation, physician and representative notification, and care plan revision for falls and changes in condition. The facility’s written policies required staff to evaluate and document all falls, including when and where they occurred and observations of events, and to identify interventions to prevent subsequent falls and address risks of serious consequences. Policies on change in condition required notifying the attending physician and resident representative of accidents or incidents involving the resident and documenting information related to changes in condition or status. Documentation policies required that the medical record contain an accurate representation of the resident’s actual experiences, including events, incidents, or accidents, and that assessments be ongoing with care plans revised as conditions change. The RN job description required ensuring compliance with policies, assessing for changes in status, notifying the physician and family or representative, documenting accordingly, and reporting incidents or unusual occurrences to nursing leadership. The lack of any fall documentation, post-fall assessment, notifications, or care plan update for the April unwitnessed fall, despite staff accounts and subsequent hospital records, constituted the failure to provide quality of care and to follow the facility’s fall, change-in-condition, documentation, and care planning protocols for this resident.
Failure to Maintain Clean, Homelike Environment in Resident Room
Penalty
Summary
The facility failed to maintain a clean, homelike environment for one resident when a privacy curtain and the ceiling above the resident’s bed remained visibly soiled for an extended period. The resident, admitted with cervical radiculopathy and depression among other diagnoses, reported that the privacy curtain between his and his roommate’s beds had not been washed for over a year. Surveyor observation confirmed two brown smears, a cluster of dark gray splatter-like spots, and an area of white crusty substance on the curtain. The resident also identified a brown splatter on the ceiling above his bed, which he stated was chocolate pudding that had been present for about nine to ten months. The resident expressed feeling frustrated that staff were not doing their jobs to keep his living environment clean. During an observation and interview, the Environmental Services Supervisor (ESS) verified the stains on the privacy curtain and the brown splatter on the ceiling and agreed they needed to be cleaned. ESS stated she conducted spot checks of rooms to ensure EVS staff were cleaning to her standards but acknowledged she had not noticed the soiled curtain or ceiling and that she and the housekeeper likely did not look up during daily cleaning and checks. ESS reported that a deep clean routine, including washing privacy curtains, had only recently been started in March 2026 and that the resident’s room had not yet received a deep clean due to a Covid outbreak that halted the process. ESS further stated that prior to March 2026 there was no set routine for washing privacy curtains or deep cleaning rooms. The Administrator stated that soiled privacy curtains absolutely needed to be changed and were expected to be washed on a routine schedule. The facility’s Homelike Environment policy indicated residents are to be provided with a safe, comfortable, homelike, clean, and sanitary environment.
Missed Suboxone Doses Due to Untimely Reordering and Unavailability
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when prescribed Suboxone for opioid dependence was not available and not administered as ordered. The resident was admitted with a diagnosis of substance dependence and had no documented memory impairment. A physician’s order dated 2/4/26 directed Suboxone sublingual film 8-2 mg, one film three times daily for opioid dependence. Review of the medication administration record for 2/26 showed that the resident did not receive Suboxone on three occasions: one evening dose on 2/23/26 and two doses on 2/24/26, with the MAR coded as “other/see Nurse Notes.” Progress notes documented that on 2/23/26 the Suboxone was pending pharmacy delivery, and on 2/24/26 it was not given and was unavailable due to the order pending the physician’s signature, and later still pending delivery. During interview, the resident reported not receiving Suboxone for a week, stated he did not know why, and reported experiencing shaking and anxiety, noting he was a recovering heroin addict. The ADON, upon review of the MAR and progress notes, confirmed the three missed doses and that the medication had not been available for administration, and stated it was her expectation that medications be ordered timely and available so doses were not missed. She further agreed that, given the resident’s use of Suboxone for opioid dependence and his complaints of anxiety and shakiness due to missed doses, this constituted a significant medication error. Facility policies on Medication Reordering and Medication Errors stated that the facility would provide medications in a timely manner to meet each resident’s needs and ensure residents receive care in an environment free of significant medication errors.
Failure to Honor Resident’s Request for Discharge and Right to Self-Determination
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to self-determination when the resident’s request to be discharged was not granted. The resident was admitted in 11/2025 with diagnoses of essential HTN and Type II DM, and a physician order dated 11/11/25 indicated the resident was capable of understanding rights, responsibilities, and informed consent. On the evening of 1/28/26, the resident told the Social Services Director that he wanted to discharge from the facility. An Alert Note dated 1/29/26 at 12:46 a.m. documented that at approximately 8:30 p.m. on 1/28/26, the resident and a visitor requested an explanation as to why the resident could not leave the facility at that time. The nurse explained that per facility protocol and due to safety concerns, the resident was not cleared to leave and that a discharge care meeting could be arranged during normal business hours, and informed the visitor that leaving would be unsafe and against medical advice. Interviews and record reviews confirmed that, despite the physician’s order deeming the resident responsible for himself, staff did not allow him to discharge and did not offer a release of responsibility form as required by facility policy for discharges without physician approval. The Social Services Director, Assistant DON, and Director of Staff Development each verified that the resident was responsible for himself and had the right to leave the facility, and the Assistant DON confirmed that staff should have offered a release of responsibility form but did not. The nurse on duty stated she told the resident it was late, that nothing could be figured out at night, there was no administrative staff available, and she did not know the procedure or what to do, believing that allowing discharge at night would compromise safety. The resident later stated by telephone that he had wanted to go home at that time but was not allowed to do so and that he was really upset and frustrated. Facility policies on “Discharging a resident without Physician’s Approval” and “Resident’s Rights” indicated that residents requesting discharge without physician approval should be asked to sign a release of responsibility form and that residents have the right to self-determination.
Failure to Report Suspected Financial Abuse to Required Agencies
Penalty
Summary
The facility failed to report suspected financial abuse of a resident by the resident’s caregiver to law enforcement, the LTC ombudsman, or the State Agency (CDPH), despite multiple staff members forming suspicions of exploitation. The resident was admitted in November 2025 with diagnoses of essential HTN and Type II DM. The Social Services Director (SSD) reported that both she and the resident’s son believed the caregiver was taking advantage of the resident’s finances and expressed concern that the caregiver was holding the resident’s credit card. The SSD acknowledged she suspected financial abuse and agreed it should have been reported as such, but she did not report it because she believed the resident had an emotional attachment to the caregiver and the resident did not complain. The Assistant Director of Nursing (ADON) stated that concerns raised by the resident’s son about the caregiver keeping the resident’s credit card and being paid while the resident remained in the facility warranted further investigation and reporting to appropriate agencies. A licensed nurse (LN B) also stated she suspected financial abuse when she learned the caregiver had the resident’s credit card and believed the caregiver used it, and acknowledged these suspicions should have been reported to CDPH and the police. Review of the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and CDPH All Facilities Letter 21-26 showed that the facility was required to identify, investigate, and report all possible incidents of abuse, neglect, exploitation, or misappropriation of property, including suspected abuse by family, friends, or other individuals, to law enforcement, the LTC ombudsman, and CDPH. These required reports were not made in this case.
Failure to Implement Physician Order for APP Mattress for At-Risk Resident
Penalty
Summary
The facility failed to ensure services met professional standards of quality when a physician’s order for an alternating pressure pad (APP) mattress was not implemented for one resident. The resident was admitted in January 2026 with diagnoses including unsteadiness in feet and dysphagia. A physician’s order dated 1/16/26 directed that an APP mattress be placed on the resident’s bed. On 2/20/26, a licensed nurse stated that physician orders should be followed and that if an APP mattress was ordered, the facility should provide it; the nurse acknowledged that failure to follow the order meant facility policy was not followed and that residents would be at risk for further skin issues. During an observation in the resident’s room that same day, another licensed nurse confirmed the resident was on a regular mattress and not on an APP mattress, and stated the resident had fragile skin and was at risk for developing pressure ulcers. In a concurrent interview and record review with the ADON on 2/20/26, the ADON verified that the resident was not on an APP mattress despite the active physician order from 1/16/26. The ADON also confirmed the resident’s Braden score was 15, indicating the resident was at risk for pressure ulcers, and stated that using an APP mattress was a preventive measure to help prevent development of pressure ulcers. The facility’s policies indicated that appropriate support surfaces should be selected based on residents’ risk factors in accordance with current clinical practice, that medications are administered in accordance with prescribers’ orders, and that staff must demonstrate skills necessary to care for residents’ needs including skin and wound care. A policy specific to physician orders was requested but not provided.
Unattended Unlocked Medication Cart Left Accessible in Hallway
Penalty
Summary
The deficiency involves failure to keep medications secured in locked compartments as required by facility policy and professional standards. During an observation and interview on 2/20/26 at 5:14 p.m., a licensed nurse left the hall 1 medication cart unlocked while inside a resident’s room, and there were no other licensed or unlicensed staff present to monitor the cart. Upon returning, the nurse confirmed that the cart had been left unlocked and unattended and acknowledged that facility policy requires medication carts to be locked when unattended for resident safety. In a subsequent interview at 5:20 p.m., the assistant DON confirmed that medication carts are required by facility policy to be locked when unattended to prevent unauthorized access to medications, and review of the written medication administration policy dated 12/2025 showed it directs that the medication cart be kept closed and locked when out of sight of the medication nurse or aide. The report states that this failure could result in access to medications by unauthorized people, leading to medication theft and unauthorized medication ingestion with a risk of overdose, drug interactions, or severe adverse effects.
Failure to Follow Infection Control Practices for Bed Linens and Nebulizer Equipment
Penalty
Summary
The facility failed to maintain infection control measures for two residents when staff did not follow established policies and procedures. For one resident admitted in January 2026 with diagnoses including unsteadiness in feet and dysphagia, a licensed nurse was observed picking up three pillows from the floor and placing them at the foot of the resident’s bed. The Assistant Director of Nursing confirmed seeing the three pillows on the bed and stated that anything that fell on the floor was considered contaminated and should not have been placed back on the bed, describing such items as soiled or dirty. The facility’s Infection Prevention and Control Committee policy indicated that the committee was to assist in the development and implementation of written policies and procedures for the prevention and control of infections among residents, provide guidelines for a safe and sanitary environment, and review, establish, and monitor environmental infection prevention and control practices in accordance with CDC, HICPAC, OSHA, and local and state requirements. For another resident admitted in December 2022 with COPD and emphysema and an order for nebulized medication every eight hours, the nebulizer mouthpiece was observed resting on top of the bedside dresser, not stored in a container or bag to protect it from cross contamination, and placed near a soda and a used drinking cup. The resident stated that staff administered the nebulizer medication but rarely kept the mouthpiece inside the provided plastic bag. A licensed nurse verified that the mouthpiece was not kept inside the plastic bag as required by facility policy and stated that after use, the mouthpiece should be stored in the bag. The Director of Nursing also verified that the mouthpiece was not in the plastic bag and was on the bedside dresser, and stated this practice was not acceptable. The facility’s policy on administering medications through a small volume handheld nebulizer required that the nebulizer equipment be rinsed and disinfected according to facility protocol and stored in a plastic bag labeled with the resident’s name and date.
Failure to Follow PICC Line Flushing and Monitoring Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and facility policy for PICC line care for one resident. The resident was admitted with metabolic encephalopathy and bacteremia and had a physician order for the PICC line to be monitored every shift on the day shift for signs and symptoms of infection. Review of the Medication Administration Record (MAR) for February showed that this monitoring order was not documented as completed on multiple specified day shifts. The resident also had a physician order for a daily heparin lock flush solution to maintain PICC line patency, which was not documented as administered on several ordered dates and times. The facility’s policy required flushing catheters at regular intervals to maintain patency, monitoring for IV complications, and recording the date and time medications were administered in the medical record. During interviews, the licensed staff member who worked several of the shifts in question confirmed that documentation of PICC line care was missing from the MAR and stated that, as he was not an RN, he could not flush the line himself and instead reminded RNs to perform the task, but could not verify it was done without documentation. He also stated he monitored the PICC site daily, although this was not consistently documented. The resident reported that staff flushed and monitored the PICC line less than half of the required times and not daily, despite his repeated reminders, and stated he felt neglected and feared infection. The DON acknowledged that a PICC line not flushed consistently could become clogged, that lack of monitoring could miss a reaction or infection, and that if a task was not documented, it meant it was not completed, confirming the missing documentation on the resident’s MAR.
Failure to Document Reasons for Missed Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation regarding the administration of medication for one resident diagnosed with left eye keratitis. The resident's Medication Administration Record (MAR) showed that several doses of a prescribed ophthalmic solution were not administered on specific dates and times. However, there was no corresponding nursing documentation explaining the reason for the missed doses. The resident's medical record lacked any notes indicating why the medication was withheld, whether the physician was notified, or what follow-up actions were taken regarding the missed medication. Interviews with the Director of Nursing (DON) and the facility Administrator confirmed that the absence of documentation did not meet the facility's expectations or policy requirements. The facility's policy on medication administration documentation requires that reasons for withholding or not administering medication be recorded, along with any related follow-up. The deficiency was identified through record review and staff interviews, which verified that the required documentation was missing for the resident in question.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure professional standards of nursing practice were followed in several instances involving medication administration. In one case, a resident with a history of cellulitis and peripheral venous insufficiency, who was cognitively intact according to her assessment, had acetaminophen left at her bedside by a licensed nurse without a physician's order for self-administration. The resident did not take the medication as intended, and her fever escalated, leading to her being found slumped and shivering, and subsequently transferred to the hospital with a diagnosis of fever and sepsis. The facility's policies required that self-administration be documented and approved by the care team, and that medications not be left unattended at the bedside, which was not followed in this instance. Additionally, the facility was found to have allowed the pre-preparation of medications for multiple residents. Staff interviews and record reviews revealed that medications were removed from their original packaging and placed in medication cups ahead of administration, with several cups containing unidentified medications left in the medication cart. Staff, including the Director of Staff Development and other licensed nurses, confirmed that this practice was not standard and posed a risk for medication errors, as it was unclear which medications belonged to which residents. The Director of Nursing was aware of these practices and, on at least two occasions, instructed staff to supervise the administration of these pre-prepared medications rather than discarding them and preparing new doses as per policy. Facility policies reviewed indicated that medications should be prepared and administered one resident at a time, with verification of the right resident, medication, dosage, time, and route. Medications were also required to be stored in their original containers until administration. The observed practices of leaving medications at the bedside without proper authorization and pre-preparing medications for multiple residents directly contravened these policies and increased the potential for medication errors and delays in care.
Delayed Physician Notification and Neglect of Change in Condition
Penalty
Summary
The facility failed to protect a resident from neglect by not promptly notifying the physician of a significant change in condition. The resident, who had a history of cellulitis and peripheral venous insufficiency, was admitted with minimal cognitive impairment. On the day of the incident, the resident exhibited a resting heart rate of 117 bpm, was shaking, and complained of being cold. Later, the resident developed an elevated temperature of 100.2°F, which progressed to a fever of 103.6°F and then 104.6°F, along with an altered level of consciousness and decreased oxygen saturation. Despite these symptoms, the physician was not notified until several hours after the initial signs of deterioration were observed. Multiple staff interviews confirmed that the resident's change in condition, including worsening redness in the leg and the development of a high fever, was recognized during the morning shift. However, the assigned nurse did not appear concerned and did not escalate the situation or notify the physician in a timely manner. The Director of Staff Development and the Director of Nursing both acknowledged that a fever is considered a change in condition that requires immediate physician notification, and that the delay in reporting constituted neglect. Documentation of the resident's symptoms, particularly the redness in the leg, was also lacking in the medical record. The facility's own policies require prompt notification of the physician and documentation of significant changes in a resident's condition. In this case, the delay in physician notification and inadequate documentation resulted in the resident experiencing delays in care, ultimately requiring hospitalization for fever, altered mental status, and sepsis. Staff interviews and record reviews confirmed that the facility did not follow its protocols, leading to the identified deficiency.
Failure to Maintain Resident Dignity and Privacy During Rectal Medication Administration
Penalty
Summary
A registered nurse (RN) failed to provide nursing care in a manner that maintained a resident's dignity and respect during the administration of a rectal suppository. The RN did not stop the procedure when the resident complained of pain and requested that the procedure be stopped. Instead, the RN continued to move her finger inside the resident's rectum for several minutes, stating it was necessary for the medication to dissolve, despite the resident's clear expression of discomfort and request to cease. Additionally, the RN did not ensure the resident's privacy during the procedure. The privacy curtain was not drawn, and the door to the hallway was left open, allowing others to see the resident partially unclothed from the waist down. This lack of privacy was confirmed by both certified nursing assistants (CNAs) present during or after the incident, with one CNA noting that the resident's buttocks were visible from the hallway. The RN also failed to adequately explain the procedure to the resident prior to performing the invasive rectal medication insertion. The facility's policy required staff to explain procedures, provide privacy, and respect residents' rights to refuse or discontinue treatment. The resident, who had intact cognitive skills and a history of depression but no other psychiatric diagnoses, reported feeling violated, embarrassed, and traumatized by the incident. The event resulted in the resident experiencing pain, anxiety, and ongoing psychological distress.
Failure to Follow Professional Standards in Rectal Medication Administration
Penalty
Summary
A registered nurse performed a digital stool dis-impaction procedure on a resident without a physician's order, which is not in accordance with professional standards of practice. The nurse inserted a rectal suppository and manipulated her finger inside the resident's rectum for several minutes, despite the resident expressing pain and asking for the procedure to stop. The nurse stated she was attempting to break up stool to allow the suppository to dissolve, and removed some stool during the process. The resident was prescribed a rectal suppository as needed for constipation, but there was no order for digital dis-impaction. The resident, who had a history of post laminectomy syndrome and constipation, reported feeling violated, embarrassed, and traumatized by the procedure. The resident's cognitive skills for daily decision-making were intact at the time of the incident. Witnesses, including a certified nursing assistant, confirmed that the procedure took significantly longer than usual and that the resident was visibly upset afterward. The resident later reported ongoing psychological distress, including nightmares and feeling unsafe in the facility. A review of facility records revealed that there was no documented competency or specific training for licensed nursing staff regarding rectal suppository administration or digital stool dis-impaction. The facility lacked a policy on digital dis-impaction, and staff interviews indicated inconsistent understanding of the correct procedures and requirements for physician orders. The facility's policy on rectal medication administration did not address digital dis-impaction, and the nurse involved believed such procedures did not require a physician's order.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the Department for one sampled resident. The resident, who had a history of post laminectomy syndrome and constipation, reported feeling violated after a registered nurse administered a rectal suppository, stating that the procedure took too long and caused discomfort. The incident was documented in the nursing notes, and the resident expressed his concerns during an interview, specifying the time and nature of the event. Despite the facility's policy requiring immediate reporting of abuse allegations within two hours, there was no evidence that the initial report was sent to the Department as required. The administrator was notified of the allegation by a charge nurse, who claimed to have faxed the report, but a review of the fax log showed no such transmission. The Department did not receive notification until the following morning, when the administrator sent the required form after confirming the initial report had not been received.
Misappropriation of Resident Property by Staff
Penalty
Summary
A certified nurse assistant (CNA) solicited and received a debit card and PIN from a resident who had diagnoses including polyneuropathy, intervertebral disc degeneration, arthritis, depressive disorder, chronic pain syndrome, and adult failure to thrive. The resident, who had no memory impairment, gave her card to the CNA after the CNA expressed financial hardship and requested a loan, with the understanding that the money would be repaid. After the transaction, the CNA did not return or communicate with the resident, prompting the resident to report the incident to facility staff. The resident expressed feeling taken advantage of and described emotional distress as a result of the incident. Facility policy, as outlined in the employee handbook and ethical house rules, strictly prohibits staff from accepting gifts, loans, or financial dealings of any kind with residents, including the removal of residents' personal belongings from the facility. Interviews with staff and the administrator confirmed that employees are not allowed to accept cash, bank cards, or any items of value from residents. The CNA involved admitted to taking the card and withdrawing money, which was in direct violation of facility policy and procedures.
Failure to Issue Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to two residents, resulting in a deficiency in beneficiary notification. Resident #244, who had a medical history of paraplegia, was admitted on June 27, 2024, and discharged home on August 19, 2024. The resident received Medicare Part A skilled services from July 11, 2024, to August 18, 2024. Despite the planned discharge and the end of Medicare coverage, the facility did not provide the required NOMNC to the resident. Similarly, Resident #245, with a medical history of rheumatoid arthritis, was admitted on September 20, 2024, and discharged on October 25, 2024. This resident also received Medicare Part A services from the admission date until October 24, 2024, but was not issued a NOMNC prior to discharge. Interviews with facility staff revealed a lack of clarity and accountability regarding the issuance of NOMNCs. The Biller and Business Office Manager were unable to explain why the notices were not provided. The Social Services Supervisor, responsible for issuing beneficiary notices, acknowledged that NOMNCs should be given two to three days before the last covered day of therapy services. The Director of Nursing and the Administrator also confirmed the expectation that NOMNCs be issued 48 hours prior to discharge, yet neither could account for the oversight. This deficiency highlights a breakdown in communication and procedure adherence within the facility's administrative processes.
Failure to Obtain Physician's Order for Respiratory Device
Penalty
Summary
The facility failed to obtain a physician's order for the use of a respiratory device, specifically an Acapella device, for a resident. The resident, who had a medical history of acute pulmonary edema and pulmonary hypertension, was observed using the device independently without a physician's order. The facility's policy required a physician's order for the use of such devices, and the device should be administered by a licensed nurse or respiratory therapist. Despite the resident's care plan indicating potential respiratory issues, the necessary order for the Acapella device was not obtained until after the surveyor's observation. Interviews with facility staff, including a Licensed Vocational Nurse and a Respiratory Therapist, revealed a lack of awareness and oversight regarding the resident's use of the device. The Respiratory Therapist acknowledged that the device was mentioned in a prior assessment but failed to secure a physician's order. The Director of Nursing and the Administrator confirmed that the facility's protocol required a physician's order for medical devices and that staff should have informed the nurse upon discovering the device at the resident's bedside. The deficiency was identified when the surveyor noted the device and prompted the facility to obtain the necessary physician's order.
Failure to Follow Mechanical Lift Policy Results in Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent a fall for a resident, identified as Resident 1, who required the use of a mechanical lift for transfers. The facility's policy mandated that at least two staff members assist with mechanical lift transfers to ensure safety. However, on the day of the incident, only one staff member, Unlicensed Staff A, assisted Resident 1 during a transfer from a wheelchair to a bed, which was against the facility's policy. Additionally, Unlicensed Staff A had not completed the required competency test for using the mechanical lift prior to the incident. This lack of training and failure to adhere to the facility's policy resulted in Resident 1 sustaining a fall, leading to a left femoral fracture. The resident, who had intact cognition and required maximal assistance for personal care, was later diagnosed with a left partial hip replacement following the injury. Interviews with various staff members, including the Director of Nursing, Licensed Staff, and other Unlicensed Staff, confirmed that the standard practice was to have two staff members present during mechanical lift transfers to prevent falls and accidents. The Assistant Director of Nursing acknowledged that the policy was not followed during the incident, which contributed to the resident's fall and subsequent injury.
Inadequate Supervision and Delayed Response Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure that Resident 1 was free from accidents due to delayed response to call lights. Resident 1, who required moderate assistance for transfers due to unsteadiness and mobility issues, fell twice while attempting to go to the toilet without staff assistance. The call light was not answered promptly, leading Resident 1 to wait over twenty minutes before attempting to transfer independently, resulting in a fall and a fractured right arm. Resident 2 was not adequately supervised while smoking, leading to cigarette burns on his right thigh and scrotum. Despite having a care plan that allowed unsupervised smoking, Resident 2's pants caught fire, and he sustained burns. The facility's smoking policy required supervision for residents with restricted smoking privileges, but Resident 2 was observed smoking without supervision or a smoking apron, contrary to the policy. Interviews with staff revealed inconsistencies in the implementation of the facility's policies regarding call light response and smoking supervision. Staff acknowledged the risks associated with delayed call light responses and unsupervised smoking, yet these policies were not consistently followed, contributing to the incidents involving Resident 1 and Resident 2.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to provide timely pain management for a resident who had undergone a left hip arthroplasty and suffered from chronic pain due to multiple surgeries. The resident reported experiencing excruciating pain because the nursing staff did not administer her pain medication according to the scheduled times. Specifically, the resident stated that it often took more than two hours to receive her pain medication after requesting it, leading to significant discomfort. A review of the resident's medical records revealed discrepancies in the administration of her prescribed medications. The Medication Administration Record (MAR) indicated that the resident was supposed to receive Oxycodone Hydrochloride ER 30 mg every twelve hours and Norco 10-325 mg every four hours. However, the Medication Administration Audit Report showed that these medications were frequently administered late, sometimes by several hours, which was contrary to the facility's policy of administering medications within one hour of the prescribed time. Interviews with the Director of Nursing (DON) and Licensed Staff D confirmed that the facility's policy allowed for medication administration within one hour of the scheduled time. However, the records indicated that this policy was not consistently followed, resulting in ineffective pain management for the resident. The DON acknowledged that there was a delay in the electronic medication administration record system but stated that it should not take an hour or more to save the nurse's signature. The failure to adhere to the medication schedule led to the resident experiencing unmanaged pain.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that three residents received showers on their scheduled days, which compromised their personal grooming and hygiene needs. Resident 5, who was admitted for physical therapy after a hip replacement, reported not receiving showers for several weeks. The Minimum Data Set (MDS) indicated that Resident 5 required partial assistance with showers, but the facility lacked electronic records to confirm whether showers were provided. The only documentation available showed a refusal on one occasion, with no further records for the month. Resident 7, diagnosed with Alzheimer's and Parkinson's diseases, was dependent on staff for showers. The facility did not provide any shower logs for Resident 7 for January and February 2024, indicating a lack of documentation and potential neglect in meeting the resident's hygiene needs. Similarly, Resident 6, who required setup or clean-up assistance, reported not receiving a shower for two weeks, leading to perineal itching. Despite being scheduled for showers twice a week, there was no documentation to confirm that these were provided, and the resident expressed dissatisfaction with the timing of the showers offered. Interviews with unlicensed staff revealed that showers were scheduled twice a week and as requested, but there was inconsistency in providing showers outside of scheduled days. The facility's policy stated that residents unable to perform activities of daily living independently should receive necessary services to maintain hygiene, yet the lack of documentation and resident reports indicate a failure to adhere to this policy. The absence of electronic records and incomplete shower logs further highlight the facility's deficiency in maintaining adequate hygiene care for its residents.
Delayed Call Light Response Leads to Resident Injuries
Penalty
Summary
The facility failed to adhere to its policy of responding to call lights within five minutes, as evidenced by the experiences of two residents. Resident 1, who required moderate assistance for transfers due to unsteadiness and mobility issues, fell twice while attempting to use the toilet without staff assistance. Despite activating the call light, Resident 1 waited over twenty minutes for assistance, leading to a fall that resulted in a fractured right arm. Observations confirmed that call lights were not answered promptly, with one instance taking eight minutes to respond. Resident 3, who was incontinent and required substantial assistance for transfers and hygiene, also experienced delays in call light response. This resident reported waiting over twenty minutes for assistance, resulting in prolonged exposure to moisture and the development of moisture-associated skin damage in the perirectal area. Interviews with staff confirmed that the facility's policy required call lights to be answered within three to five minutes, yet this standard was not consistently met. Interviews with facility staff, including unlicensed personnel and the Director of Staff Development, highlighted the expectation for call lights to be answered promptly to prevent safety issues. The facility's policy, dated September 2022, mandated that calls for assistance be answered within five minutes, with urgent requests addressed immediately. However, the failure to meet these standards led to significant negative outcomes for the residents involved.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of pain medications Oxycodone and Oxycontin. The resident, who had undergone a left hip arthroplasty and had a history of chronic pain due to multiple surgeries, was prescribed Oxycodone Hydrochloride ER 30 mg to be taken every twelve hours. However, records indicated that the medication was administered more frequently than prescribed, with doses given at 6:00 a.m., 8:00 a.m., and 9:00 p.m. on one occasion. Additionally, a subsequent order for Oxycontin 20 mg to be taken every twelve hours was also not followed correctly, with doses administered at 4:00 a.m., 8:30 a.m., and 9:00 p.m. Interviews with the Director of Nursing and Licensed Staff D revealed that the facility's policy required nurses to verify the right medication and dosage before administration, allowing a one-hour window before or after the scheduled time. Despite this policy, the medication was not administered as prescribed, leading to potential risks for the resident. The facility's policy on administering medications, revised in April 2019, emphasized the importance of checking the medication label three times to ensure the correct resident, medication, dosage, time, and method of administration.
Call Light System Malfunction
Penalty
Summary
The facility failed to ensure that the call light system was in good working condition for one of the residents, identified as Resident 8. This deficiency was observed during a review of the resident's records, interviews, and direct observations. Resident 8, who was admitted with diagnoses including age-related cognitive decline, COPD, and muscle weakness, had a BIMS score indicating cognitive intactness and required assistance with transfers. On a specific date, Resident 8 was found lying on the floor next to her bed, and during subsequent interviews, it was revealed that her call light had not been functioning for a long time. Another resident, Resident 6, confirmed that she would activate her own call light to assist Resident 8 when needed. During an observation, it was confirmed that Resident 8's call light did not activate, while Resident 6's call light was functional. Unlicensed Staff B verified that the call light connector in Resident 8's room was obstructed by dirt or grease, preventing a proper connection. After cleaning the connector, the call light was restored to working order. The Maintenance Director stated that daily room rounds were conducted to test call lights, but he had not received any reports about Resident 8's call light malfunctioning. The facility's policy requires that the resident call system remains functional at all times, which was not adhered to in this case.
Inaccurate MDS Completion for a Resident
Penalty
Summary
The facility failed to ensure the accurate completion of the Minimum Data Set (MDS) for one of the sampled residents, leading to incomplete information necessary for developing a resident-centered care plan. The resident in question was admitted with diagnoses including unsteadiness on feet and other abnormalities of gait and mobility. The MDS dated for the resident indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, suggesting cognitive intactness. However, during an interview and concurrent record review, it was revealed that the MDS assessment for the resident was inaccurately completed, with several areas such as eating, maintaining oral and personal hygiene, showering/bathing, dressing, and footwear not assessed or lacking information. The MDS Coordinator acknowledged the inaccuracies in the MDS assessment and confirmed her responsibility for ensuring its accuracy. The facility's policy on comprehensive assessments and care delivery, revised in December 2016, outlines the process of collecting and analyzing information, choosing and initiating interventions, and monitoring results. It also specifies that the MDS should be completed within 14 days after admission. The failure to accurately complete the MDS assessment resulted in a lack of complete information necessary to meet the resident's healthcare needs.
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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